Adoption Client Intake Form — Bell Law Co.

Adoption Client Intake Form

Please complete this form as thoroughly as possible. All information is confidential and will be used to prepare your adoption petition. Some fields are optional — fill in what you know.

Family

Parent(s)

Child(ren)

Birth Mother

Birth Father

Additional

Who is adopting?

This helps me tailor the form to your situation.

Single Person

Married Couple

Stepparent Adoption

Step 1 of 6

Adopting Parent(s)

Contact information, residence, and background for the petition.

Adopting Parent

First Name *

Last Name *

Middle Name

Date of Birth *

Email *

Phone *

State of Birth *

Race / Ethnicity * Required for the birth certificate application (§ 9-9-219).

Current Address

Street Address *

Address Line 2

City *

State *

ZIP *

Date You Moved to This Address * Required to establish residence for the petition.

Occupation at Time of Child's Birth Applies to the male adopting parent, if any.

Second Adopting Parent

First Name *

Last Name *

Middle Name

Date of Birth *

Phone

State of Birth *

Race / Ethnicity *

Marriage Information

Required for the Petition Arkansas law requires the petition to state the date and place of marriage if the petitioner is married. § 9-9-210(a)(5).

Date of Marriage *

Location of Marriage *

Prior Births or Adoptions — Second Adopting Parent

Why I ask For the adoptive mother (or the second parent if applicable), Arkansas requires us to report the number of living children, children born alive but now deceased, and children born deceased. This information is required to obtain the child's new birth certificate after the adoption is complete. § 9-9-219.

Prior Births or Adoptions

Step 2 of 6

Child(ren) to Be Adopted

Add each child separately. If the child has not yet been born, fill in what you know.

Step 3 of 6

Birth Mother

This information is required for the petition and consent process. Fill in as much as you know.

Consent Requirement In almost all cases, the birth mother's written consent to adoption is required and must be executed after the child's birth before a notary or the court. § 9-9-206(a)(1), § 9-9-208.

Birth Mother Identity

First Name *

Last Name *

Middle Name

Maiden Name

Date of Birth

Phone

Birth Mother Address

Street Address

City

State

ZIP

Marital Status

Birth Mother's Marital Status at Time of Conception or Anytime After * This determines whether the birth father's consent is required and whether the Putative Father Registry must be checked. § 9-9-206, § 9-9-224.

Husband's Name and Any Details You Know

Step 4 of 6

Birth Father

Birth father information, involvement, and consent status.

Birth father is unknown or cannot be located

Skip the fields below and I'll note this in my records.

Birth Father Identity

First Name

Last Name

Middle Name

Date of Birth

Phone

Birth Father Address

Street Address

City

State

ZIP

Birth Father Status

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

Describe the Birth Father's Involvement With the Child This helps determine whether his consent is required. § 9-9-206(a)(2). If there has been no meaningful relationship, his consent may not be required under Arkansas law.

Step 5 of 6

Additional Information

A few final questions before we submit.

📋 Information We Will Collect in Person or Securely I will collect Social Security numbers for the child, birth mother, and birth father (if known) by phone before we meet. Please do not include them here.

Open Adoption

Are you interested in a voluntary post-adoption contact agreement with the birth parent(s)? A post-adoption contact agreement is voluntary and does not affect the adoption itself. It can address information sharing, communication, or visitation. § 9-9-225.

Type of Adoption

What best describes your adoption situation?

Anything Else

Is there anything else you'd like me to know about your situation?

How Did You Find Me?

How did you hear about Bell Law Co.?

Step 6 of 6

✓

Thank you!

Your intake form has been received.

Adoption Client Intake Form

Thank you!

Evan C. Bell