Adoption Questionnaire

CONFIDENTIAL

Husband & Wife First & Last Names:	At least one name is required.
Address:
City:	State: Zip Code:
Home Phone:	( ) - Fax Number: ( ) -
Referred By:

	Husband	Wife
Work Phone:	( ) -	( ) -
Cell Phone:	( ) -	( ) -
E-mail Address:
Age:
Race:
Date of Marriage
Previous Marriage(s):
Reason for Ending Previous Marriage(s):
Number of Children from Previous Marriage(s):
Religious Affiliation:
Active Religious Member:	Yes No	Yes No
Occupation:
Annual Income:
Health Status:
Infertility Issues:	Yes No	Yes No
Have you ever been arrested?	Yes No If so, when and what were the charges?	Yes No If so, when and what were the charges?

Age and sex of children in your family (Indicate if biological or adopted, what race or nationality):

Career plans for parents after adoption (i.e., take a leave-of-absence, return to work, full-time, part-time, or stay at home):

Travel - If required, could you and/or your spouse travel?

Maximum Time you could be away:

Finances - What is the maximum fee you are willing to consider for your adoption?
Note: Most of our sources' fees range from $30,000 to $40,000 plus for Caucasian, Hispanic, or Asian; $16,000 to $28,000 for minority (i.e. African American or part African-American). Please indicate the fee range you would consider. It is not necessary to have all funds available when you begin your adoption process.

Description of child you would consider for adoption (Choose all that you would consider):

What age child (children) would you accept?	newborn	3 to 12 months	1 year to 5 years
How many children would you feel comfortable accepting?	1 child	twins	siblings

Race of Child:

Caucasian	Yes	Would Consider	No
Hispanic/Caucasian	Yes	Would Consider	No
Hispanic	Yes	Would Consider	No
Native American/Caucasian	Yes	Would Consider	No
Native American	Yes	Would Consider	No
Asian/Caucasian	Yes	Would Consider	No
Asian	Yes	Would Consider	No
African American/Caucasian	Yes	Would Consider	No
African American	Yes	Would Consider	No

Most of our sources place newborns from the United States. If you are interested in adoption a child internationally we can assist you with this as well. Please indicate countries that you have specific interest in pursuing.

Level of openness between Adoptive Parents and Birth Parent: (Most of our clients are open to "semi-open confidential." They are willing to prepare a non-identifying profile; open to meeting birth parent before the adoption; and sharing letters/pictures through the agency after the adoption. Please comment on your comfort level with the above):

Additional Information

Please tell us anything else about yourself or the child you would like to adopt that will assist us in finding appropriate sources for you. What is most important to you in pursuing this adoption (i.e., time frame, cost, age of the child, your ability to travel, etc.)?:

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