Intake Form: Adoption

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There's no denying that the adoption process involves a lot of paperwork. If you are seeking the aid, advice, and counsel of an adoption attorney, he or she will guide you through the mountains of paper that lead to your child. In order to do so, you will need to provide your attorney with a vast amount of information. You can expedite the process by completing the following questionnaire before your first meeting with your lawyer.

ADOPTIVE MOTHER	ADOPTIVE FATHER
Name________________________________	______________________________
Date of Birth___________________________	______________________________
Social Security Number__________________	____________________
Address, Including County
Length of Time at that Address    _______ years	_______ years
Previous Address(es) (for last 10 years)
Home Telephone Number ____________________	____________________
Work Telephone Number ____________________	____________________
Facsimile Number ____________________	____________________
E-mail Address ____________________	____________________
Former Name(s) ____________________	____________________
____________________	____________________
Employers ____________________	____________________
Position ____________________	____________________
Employer's Address
______________________________	______________________________
______________________________	______________________________
______________________________	______________________________
Length of Time with Employer _______ years	_______ years
Previous Employer(s) (for last 10 years)
______________________________	______________________________
______________________________	______________________________
______________________________	______________________________
______________________________	______________________________
Gross Monthly Income $_________________	$_________________
Other Income
Source/Amount ________________________	_________________________
Source/Amount ________________________	_________________________
Source/Amount ________________________	_________________________
Date of Marriage _________________________________
Place of Marriage ________________________________
Previous Marriage(s)   Yes ____    No ____	Yes ____   No ____
Ended by:	Ended by:
Death ____ Divorce ____ Date ______	Death ____ Divorce ____ Date _____
Death ____ Divorce ____ Date _____	Death ____ Divorce ____ Date _____
Children of Current Marriage
Name                                         Date of Birth	Adopted?        Living in home?         Race/Nationality
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
Children from Other Marriages or Relationships
Name                                         Date of Birth	Adopted?        Living in home?         Race/Nationality
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
_______________________   _________	Yes/No                 Yes/No                     __________
I/we am/are interested in (check all that apply): Domestic Adoption _____    Intercountry Adoption _____    Open Adoption _____ Closed Adoption _____    Infant Adoption _____ (under 12 months) Older Child _____ (state desired age range _____-_____)    Sibling Groups _____ Do you have a gender preference? Yes, I/we prefer a ___________.    No _____ State desired race or ethnicity of child(ren), if any.    _____________________ If you are contemplating intercountry adoption, are there particular countries you are interested in?  _______________________ I/we have the following amount available to fund the adoption (may affect options that can be pursued): Up to $1,000 _____    $1,000 to $5,000 _____    $5,000 to $10,000 _____ $10,000 to $20,000 _____    $20,000 to $30,000 _____    Over $30,000 _____ Do you have a completed home study?    Yes _____ No _____ Has an adoption ever been denied to you?    Yes _____ No _____ Have you ever been arrested?    Adoptive mother: _______     Adoptive father: _______ If yes, explain: Are you in good health?    Adoptive mother: ________ Adoptive father: _______ Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information: Do you have a history of alcohol or drug abuse?    Adoptive mother: ________    Adoptive father: ________ List three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.
Name                        Address	Relationship            How long known?
______________    ____________________	_______________    ____________
______________    ____________________	_______________    ____________
______________    ____________________	_______________    ____________
Other Important Information Questions to Ask My Attorney