Pact, An Adoption Alliance - Adoptive Parent Questionnaire

Getting to Know You

Each parent should fill out this form separately.

The information you provide will be helpful for many reasons. It will help identify services you need and want. It will also help birth parent(s) get to know you. Please answer the questions as completely as you can. Birth parents clients of Pact have been asked to fill out an equivalent form.

Personal History:

Name: Maiden Name:

Mailing Address: City, State, Zip:

Email Address:

Work Phone: Home Phone:

Fax: Phone Card:

Date of Birth: Age:

Race: Nationality:

Occupation: Education: (last grade completed)

Do you have a police record? No Yes Have you ever been arrested? No Yes

If yes, describe circumstances including where and when:

Describe your community. What is the racial makeup of your community?

Do you have any significant health issues? Describe:

How actively do you participate in your current religion if at all? Describe:

Feelings About Adoption

Do you have children? No Yes Do you have step-children? No Yes

How many children? What ages?

Are any of your children adopted? No Yes Adopted transracially? No Yes

What races?

What is your experience with adoption? (check all appropriate boxes)

Are you adopted a birth parent an adoptive parent

Is anyone in your family adopted a birth parent an adoptive parent

If so, what is your relationship to them?

Do you personally know anyone who is adopted a birth parent an adoptive parent

If so, what is your relationship to them?

Have you ever placed a child for adoption? No Yes Have you ever had a failed adoption? No Yes

How do you think it would feel like to grow up as an adopted child in a family?

What do you think your concerns would be if you were unable to parent your child yourself
and had to consider placing him or her for adoption?

What worries you about taking part in an adoption?

Do you have your heart set on adopting a particular kind of child? Describe:

Describe any child you can not accept:

Describe how racial issues matter in an adoption:

Why are you committed to adoption as a way to add to your family? What made you decide?

Is there anything that might make it hard for you to be selected as an adoptive parent?

Summarize your decision making style:

Who else knows about your adoption plans? What do they think?

What kind of ongoing contact do you want with the birth parents?

What do you want your child to know about his or her birth family and adoption?

What do you think your child will want to know about his or her birth family? adoption?

If you are married or in a committed relationship, do you and your partner have any differences
between you in regard to your thinking about adoption?

What do you respect most about your partner's attitudes about adoption?

Can your marriage or relationship continue without a child? Describe:

After you adopt will you be using supplemental child care? If so, starting when and how often?

Is there anything else you think we should know?

Name:		Maiden Name:
Mailing Address:		City, State, Zip:
Email Address:
Work Phone:		Home Phone:
Fax:		Phone Card:
Date of Birth:		Age:
Race:		Nationality:
Occupation:		Education: (last grade completed)

Do you have a police record?	No Yes	Have you ever been arrested?	No Yes
If yes, describe circumstances including where and when:

Do you have children?	No Yes	Do you have step-children?	No Yes
How many children?		What ages?

Are any of your children adopted?	No Yes	Adopted transracially?	No Yes
What races?

What is your experience with adoption? (check all appropriate boxes)

Are you	adopted a birth parent an adoptive parent



Is anyone in your family	adopted a birth parent an adoptive parent
If so, what is your relationship to them?



Do you personally know anyone who is	adopted a birth parent an adoptive parent
If so, what is your relationship to them?