James 1:27
Pure religion and undefiled before God and the Father is this, To visit the fatherless and widows in their affliction, and to keep himself unspotted from the world.

Loving Shepherd Ministries
P.O. Box 375
Bluffton, IN 46714

Phone
(260) 824-9000

Fax
(260) 824-9002
Banner
jen@loving-shepherd.org

For Married Couples referred by Christian Aid Ministries

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 family’s specific needs.

For an international adoption, each country has its own specific guidelines, restrictions and regulations. For a domestic adoption (within the U.S.) your family would work with an adoption agency or with a birth mother through a lawyer. In either case, adoption will require a home study so the adoption agency, birth family and/or international country would know the particulars about your specific lifestyle. Below are questions which would be factors in an adoption. In order to more effectively help your family, please answer the below questions:

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   No   How many "divorces"?
Has Wife been divorced?
  Yes   No   How many "divorces"?
Husband Employment Status
  Full Time   Part Time   Not Employed
Wife Employment Status
  Full Time   Part Time   Not Employed
U.S. Citizen
  Husband:  Yes No
       Wife:  Yes No
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 No
Ages and gender of domestically adopted children
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
What Adoption Organization(s) did you adopt with?
Ages and gender of internationally adopted children
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
Age:  Male: Female:
What Adoption Organization(s) did you adopt with?
Do you have a current Home Study?
  Yes No
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   Domestic   Either
How many children are you considering adopting at this time?
Do you have a gender preference for this adoption?
  Male   Female   Either
Do you have an age preference for this adoption?
  Yes No
If "Yes", what age category are you interested in?
Do you have a nationality preference for this adoption?
  Yes No
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 No
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   No   Some Concerns
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   No   Some Concerns
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   No
There typically are emotional issues an adopted child must deal with. Are you prepared for those challenges?
  Yes   No
Would you consider adopting a child who is physically challenged?
  Yes   No
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   Have Taken In The Past
  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   No
Have either of you ever been charged with or convicted of a felony or misdemeanor, other than a minor traffic violation?
  Yes   No
If you answered “Yes,” please explain and include how long ago the incident(s) occurred.
Has Husband had traffic violations issued?
  Yes   No   If "Yes", how many?
Has Wife had traffic violations issued?
  Yes   No   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
Does your family have electricity in your home?
  Yes   No
Does your family have access to a computer and internet and are you able to communicate via the internet?
  Yes   No
Does your family have access to a phone?
  Yes   No
Does your family have a motor vehicle for transportation?
  Yes   No
Are you willing to provide pictures of yourself, family and home for the purposes of a home study and passport?
  Yes   No
Are you willing to travel by air if pursuing an international adoption?
  Yes   No
Does your family have medical insurance?
  Yes   No
Will the cost of the adoption process place a financial burden on your family?
  Yes   No
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   No
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   No
Would your family like to be added to Loving Shepherd Ministries e-newsletter?
  Yes   No