Adoptive Step-Parent Intake Form

Assisting Families
For More Than 30 Years

Our Practice Is Limited to Adoption & Children's Law

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Contact Information

Date:

Husband’s Legal Name

Wife’s Legal Name (Please list wife’s name as it should appear on legal documents & vital record forms)

Wife’s Maiden Name

Marriage Date

City

State

Home Address

City

State

Zip

Country

Home Phone

Fax

Who should we call first? Husband Wife

Cell (his)

Cell (hers)

Business(his)

Business(hers)

Email (his)

Please enter a valid email address.

Email (hers)

Please enter a valid email address.

Children

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

(If more than 5, please list under additional notes section at the end of this form)

Family Information

Adoptive Father

Date of Birth

Place of Birth

Race

Occupation

Adoptive Mother

Adoptive Mother

Date of Birth

Place of Birth

Race

Occupation

Please list any additional languages that either of you speak:

Information of Child(ren) to be Adopted

Child 1: Full Birth Name

Date of Birth

Gender

Race

Place of Birth: Hospital Address

Hospital City

State

Zip

Country

Date of Conception

Place of Conception: City

State

Name as you wish it to appear on amended birth certificate:

For vital bio records, what is the mother’s maiden name?

Child 2: Full Birth Name

Date of Birth

Gender

Race

Place of Birth: Hospital Address

Hospital City

State

Zip

Country

Date of Conception

Place of Conception: City

State

Name as you wish it to appear on amended birth certificate:

For vital bio records, what is the mother’s maiden name?

Birth Mother/Father Information

Legal Name

Maiden Name (if applicable)

Phone Number

Date of Birth

Place of Birth

Race

Last Known Address

City

State

Zip

Amount of visitation in the last 3 years:

Amount of child support paid in the last 3 years

Were you married to the biological father/mother?
Yes No

If so, what was the marriage date?

Divorce Date

County where finalized

State

How did you hear about our office?

Any additional notes?

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Assisting Families
For More Than 30 Years

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Assisting Families For More Than 30 Years

Adoptive Step-Parent Intake Form

Assisting Families
For More Than 30 Years