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Adoptive Parent Application & Intake Form

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Contact Information:

Your Name:____________________________________________________
.......... First Middle (Maiden) Last

Address: ____________________________________________________

____________________________________________________

Work Phone: ________________ Home Phone: ______________________

Cell Phone/Pager Number: __________________ Fax: __________________

Calling Card Type & Number: _______________________________________

Best Time & Place to Call: _________________________________________

Email Address: _________________________________________________

Name of Spouse/Partner: _________________________________________

Personal History:

Date of Birth: ________________ Social Security #: _______________

Place of Birth: ________________ Sex: _______________________

Nationality/Ethnicity: ___________________ Race: _____________________

Primary language spoken in your home: _________________________________

Citizenship: U.S. Other: _______________________________

Marital Status: Married Single Divorced Separated Widowed

Occupation: _________________________________________________

Name of Current Employer: _________________________________________

Years Employed in Current Position: ________ Salary/Wage: ___________

Last Grade/Degree Completed: ____________________________________

Date Completed: _______________ Name of School: __________________

Military Service: No Yes If yes, what branch? ______________

Religion: __________________ How active are you in your religion?

______________________________________________________________

Are there any other adults living in your home (other than the spouse/partner listed above)?
No Yes

If yes, please list each person’s name, age, sex and relationship to you.

1) __________________________________________________

2) __________________________________________________

Are you a parent? No Yes

If yes, please list the names, ages, and sex of your children and whether they are adopted or biological. If any of your children do not live with you, please also indicate where and with whom they live.

1)            __________________________________________________

2)      __________________________________________________

3)      __________________________________________________

4)            __________________________________________________

Have you ever been arrested? No Yes

Do you have a criminal record? No Yes

If you answered yes to either of the above questions, please describe the
circumstances including the date, place and resolution or sentence:

______________________________________________________________

Do you have any significant medical condition(s) that may limit your ability to care for a child:
No Yes If yes, please describe:

______________________________________________________________

What is your direct experience with adoption? (please check all that apply):

I am adopted

I am an adoptive parent

I have placed a child for adoption

This is my first adoption experience

Do you have relatives that are adopted, have adopted a child or have placed
a child for adoption? No Yes

If yes, please describe their adoption experience and their relationship to you:

______________________________________________________________

Do you have friends who are adopted, have adopted a child or have placed a child for adoption?
No Yes If yes, please describe their adoption experience and their relationship to you:

______________________________________________________________

Your Feelings About Adoption

Why do you think adoption is the best step in your life right now?

______________________________________________________________

What are your concerns about adopting a child?

______________________________________________________________

Which of the following racial heritages would you consider for your child
(please check all that apply):

Black/African-American Bi-Racial Black/Caucasian

Latino Bi-Racial Black/Latino

Caucasian Bi-Racial Caucasian/Latino

If you are considering adopting transracially, please read Below
The Surface, a self-assessment guide for anyone considering adoption
across racial or cultural lines and complete the self-assessment.

Are you looking for a particular kind of child? If so, please describe what that
child might be like:

______________________________________________________________

Please describe the characteristics of any child you cannot accept:

______________________________________________________________

How do you think your child will feel about being adopted?

______________________________________________________________

What do you think your child would want to know about his/her birth parents and the
circumstances of his/her adoption?

______________________________________________________________

If you were a birth parent, what concerns would you have about making an adoption
plan for your child?

______________________________________________________________

Do you and your spouse/partner have any differences of opinion about adopting a child?
No Yes If yes, please explain:

______________________________________________________________

What is the best thing about your relationship with your spouse/partner that will
contribute to the healthy rearing of a child?

______________________________________________________________

How do you make decisions in your life?

______________________________________________________________

Have you told friends or relatives about your intention to adopt? No Yes

If yes, please describe their reaction(s):

_______________________________________________________________

______________________________________________________________

Please describe anything about you or your life situation that might make it hard for
birth parents to choose you as the adoptive parents for their child:

______________________________________________________________

If you could, would you like to:

Talk on the phone with the

birth parents? No Yes Not Sure

Meet the birth parents? No Yes Not Sure

Would you like to have ongoing contact with the birth family? No Yes
If yes, please describe the type of contact (for example, pictures and letters, telephone
conversations, visits etc.) and the frequency (once a year, once a month, once a week etc.):

______________________________________________________________

After you adopt, will you be a stay at home/full-time parent? No Yes

If no, please describe your child care plans:

_________________________________________________________

How did you hear about Bright Futures?

_______________________________________________________

Is there anything else we should know?

______________________________________________________________

I have completed this Adoptive Parent Application and Intake Form to the best of my ability.

___________________________

(Signature of Adoptive Parent)

___________________________

(Date)