Pre-Adoption Assessment Form For Single Parents
Applicant's Full Name
Age
Street Address
City
State
Zip
Phone
Fax
E-mail Address
Number of previous marriages
Employment Status
Full Time
U.S. Citizen
Yes
Number of birth children in family
Ages and gender of birth children
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Have you adopted previously?
Yes
Ages and gender of domestically
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
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What Adoption Organization(s) did you adopt with?
Ages and gender of internationally
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
Female:
Age:
Male:
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Age:
Male:
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What Adoption Organization(s) did you adopt with?
Do you have a current Home Study?
Yes
There are many reasons people wish to adopt. Please share your reasons for considering adoption.
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 identify the areas which would be a challenge.
Would a child with physical or mental 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
Applicant's health status
Have you 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 currently taking asthma medication or being treated for asthma?
Yes
Have you ever been charged with or convicted of a felony or misdemeanor, other than a minor traffic violation?
Yes
If "Yes", how many?
Has Husband had traffic violations issued?
Yes
If "Yes", how many?
Have you 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 applicant
Church affiliation
None
Will the cost of the adoption process place a financial burden on you?
Yes
What is your total income from all sources (not including welfare subsidy, relief fund, pension, unemployment insurance or other form of government subsidy)?
What are your total monthly debt payments including mortgage payment?
What are your total assets (what you own)?
What is your total amount of debt (what you owe)?
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
