Pre-Adoption Assessment Form For Married Couples To ensure Loving Shepherd can give you the most accurate options when considering adoption, please fill out the entire form. The more thoroughly you answer the questions, the better we will be able to provide you with information that will lead you to the type of adoption best suited for your specific needs. Please use additional sheets as necessary to give complete answers.
Husband's Full Name
Age
Wife's Full Name
Age
Street Address
City
State
Zip
Phone
Fax
E-mail Address
Date of Marriage
Has Husband been divorced?
Yes
Has Wife been divorced?
Yes
Husband Employment Status
Full Time
Wife Employment Status
Full Time
U.S. Citizen
Husband: Yes
Number of birth children in family
Ages and gender of birth children
Age:
Male:
Female:
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Male:
Female:
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Female:
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Male:
Female:
Have you adopted previously?
Yes
Ages and gender of domestically
Age:
Male:
Female:
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Female:
Age:
Male:
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Age:
Male:
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What Adoption Organization(s) did you adopt with?
Ages and gender of internationally
Age:
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What Adoption Organization(s) did you adopt with?
Do you have a current Home Study?
Yes
There are many reasons couples wish to adopt. Please share your reasons for considering adoption.
Is infertility an issue?
What type of adoption are you considering?
International
How many children are you considering adopting at this time?
Do you have a gender preference for
this adoption?
Male
Do you have an age preference for this adoption?
Yes
If "Yes", what age category are you interested in?
Do you have a nationality preference for this adoption?
Yes
If "Yes", what countries have you
been considering?
Knowing the adoption process can easily take 1 year or more, how soon would you be ready to start the adoption process?
Have you had any past negative personal experiences with adoption proceedings or indirectly regarding someone else's experiences?
Yes
If you answered "Yes", please describe.
Would a child of a different race, ethnic background or culture be accepted in your social & family structure?
Yes
If you answered "No" or "Some concerns", please specify your family's desired ethnicity when pursuing adoption.
Would a child with physical or emotional challenges be accepted in your social and family structures?
Yes
If you answered "No" or "Some Concerns", please identify the areas which would be a challenge.
Would you consider adopting a child who is mentally challenged?
Yes
There typically are emotional issues an adopted child must deal with. Are you prepared for those challenges?
Yes
Would you consider adopting a child who is physically challenged?
Yes
Husband's health status
Wife's health status
Have you or your spouse ever taken or are you currently taking medication for depression or anxiety?
Never Taken
Taking Currently
a. If you have taken medication for depression or anxiety in the past, how long has it been since you have taken this medication?
b. If you answered “Have taken in the past” or “Taking currently,” please explain the situation that resulted in the need for medication.
Are you or your spouse currently taking asthma medication or being treated for asthma?
Yes
Have either of you ever been charged with or convicted of a felony or misdemeanor, other than a minor traffic violation?
Yes
If you answered “Yes,” please explain and include how long ago the incident(s) occurred.
Has Husband had traffic violations issued?
Yes
If "Yes", how many?
Has Wife had traffic violations issued?
Yes
If "Yes", how many?
Have you or your spouse ever abused alcohol or drugs or have a history of domestic abuse (including sexual abuse), even if you were not arrested or convicted? If “Yes”, please explain and include how long ago the incident(s) occurred. Any information provided to Loving Shepherd will be kept strictly confidential.
Religion of applicants
Church affiliation
None
Will the cost of the adoption process place a financial burden on your family?
Yes
What is your total income from all sources (not including welfare subsidy, relief fund, pension, unemployment insurance or other form of government subsidy)?
The adoption process requires full disclosures of physical & mental health, financial history, and federal, state and local background checks including fingerprinting. Are you comfortable with those disclosures?
Yes
Please share how you heard about our services at Loving Shepherd Ministries (family/friend referral, church, web search, LSM newsletter/presentation, etc.)
Would you like additional informaton on other Loving Shepherd
Ministries services or a informational packet for your church?
Yes
Would your family like to be added to Loving Shepherd Ministries
e-newsletter?
Yes
