ADOPTION CLIENT INTAKE FORM

Adopting Parent 1 Name

First Name

Last Name

Adopting Parent 2 Name

First Name

Last Name

Adopting Parent 1 Email

Adopting Parent 2 Email

Adopting Parent 1 Phone

(###)

###

####

Adopting Parent 2 Phone

(###)

###

####

Adopting Parent 1 Date of Birth

YYYY

Adopting Parent 2 Date of Birth

YYYY

Adopting Parent 1 Race

Adopting Parent 2 Race

Adopting Parent 1 State of Birth

Adopting Parent 2 State of Birth

Adopting Parent 1 Occupation at Time of Child's Birth

Applies only to the male Adopting Parent.

Adopting Parent(s) Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adopting Parent(s) Current Address Beginning Date

When did you move into your current home?

YYYY

Date of Marriage of Adopting Parents (if applicable)

YYYY

Prior Births or Adoptions of Adopting Parent 2

For the adoptive mother, please list the number of living children (not including the Child to be adopted), the number of children born alive but now deceased, and the number of children born deceased. I know this is a very strange question, but this information is required for the form to obtain a new birth certificate for the Child you are adopting.

Child's Current Full Name (Pre-Adoption)

Child's New Full Name (Post-Adoption)

Child's Date of Birth

YYYY

Child's Social Security Number

Location of Child's Birth (Hospital/City/State)

If the child is not yet born, provide where you anticipate he/she will be born.

Has the Child been Adopted Before?

When and How Child Came Into Adopting Parent(s) Care

If the child is not yet in your care, write "N/A."

Child's Current Address (if Different from Adopting Parent(s))

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Property and Estimated Value

Describe and estimate the value of any property of the individual to be adopted (i.e., bank accounts, social security, trust fund, etc.), if anything.

Birth Mother Name

Please include middle name, if known.

Birth Mother Maiden Name

Birth Mother Email

Birth Mother Phone

(###)

###

####

Birth Mother Date of Birth

YYYY

Birth Mother Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Mother Social Security Number

Birth Mother Marital Status at Time of Child's conception or anytime after?

If Birth Mother was ever married, please provide the name and any other details you have about her husband(s).

Birth Father Involvement

If the birth mother was not married at the time of the child's birth, please describe the birth father's involvement (if any) in the child's life and whether he has a relationship with the child.

Is the Birth Father on the Child's Birth Certificate?

Birth Father Name

Please include middle name, if known.

Birth Father Email

Birth Father Phone

(###)

###

####

Birth Father Date of Birth

YYYY

Birth Father Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Father Social Security Number

How did you hear about my services?