? Adoptive Parent Intake Form
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Adoptive Parent Intake Form


Last Name
Husband First
age
Wife First
age
Address
City
State
Zip
Home Phone
Home Fax
Husband Cell
Wife Cell
Husband Business Phone
Wife Business Phone
Business Fax
Best Time and Place to be Reached

Emergency Contacts

Name
Relationship
Phone Number
Name
Relationship
Phone Number
Name
Relationship
Phone Number

Personal Info

Marital Status
How Long
Number of previous marriages
Number of Children
Ages of Children
Number of Children at Home
Previous Adoptions
Education Husband
Education Wife
Medical Challenges Husband
Medical Challenges Wife
Criminal Record Husband
Criminal Record Wife
Religious Affiliation
Ethnic Background Husband
Ethnic Background Wife

Who Referred you to us?


Homestudy Agency


Business Name
Contact Name
Phone Number
Address:

Date Ready

Local Attourney


Business Name
Contact Name
Phone Number
Address:

Budget

Budget Preference
Budget Limit
Cash Liquidity - Amount
Tolerance for Risk
Willingness to pay fees at match
How early do you feel comfortable matching?
Will Travel:
Before or at Delivery
only after surrenders are signed

Desired Child Profile

RACE
Full Cau
Cau/Hisp
Cau/Asian
Cau/Native Am.
Full Hisp
Full Asian
Full Cau
Cau/AA
Full AA
Don't Want
AGE
Newborn
Newborn to 1 yr old
Older Child
Sibling Group
Twins
SEX
Boy or Girl
Boy Only
Girl Only
HEALTH
Healthy Only
Mild Problems
Moderate Problems
Special Needs
DRUG EXPOSURE
Illegal Drugs:
Alchohol:
Smoking:
BIRTHMOTHER MEDICALS
I must have birthmother medicals before I feel comfortable committing to a situation
I can wait till after the match
The medicals would be nice but I can do without
The medicals are not important to me
CONTACT WITH BIRTHMOTHER
No Contact: before adoption after adoption
Pictures & Letters: before adoption after adoption
Phone Contact: before adoption after adoption
Visits: before adoption after adoption



Just have some questions?
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E-Mail:
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This Email form is the best way to contact us. We will respond via email as soon as possible. You may call Jenn between 12 & 3 p.m. at 804-269-0662. Leave a message if she is busy. Please try to ensure that all information is as accurate as possible to prevent any delays or problems in communication.

Minority Adoptions
Home | How we Work | Costs | Working with Us | Roll-over | Open Adoption | Parents & Pros | Parent Intake | Minority | Q & A