Home Study Information Form

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Please complete the following questionnaire as thoroughly as possible. All information given will be kept confidential and used only for the purposes of writing a home study report for your family. Please retain a completed copy for your records.

IDENTIFYING INFORMATION

Ap 1 - Full Legal Name: (As it appears on your passport)(Required)

First Middle Last Suffix

Preferred Name(Required)

First Last

Maiden Name

First Last

Ap 2 - Full Legal Name: (As it appears on your passport)(Required)

First Middle Last Suffix

Preferred Name(Required)

First Last

Maiden Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Phone (Home)(Required)

Email (s)(Required)

Ap 1 Work Phone

Ext.

Ap 2 Work Phone

Ext.

Date Married (If Applicable)

Place of Marriage

SOCIAL INFORMATION

Ap 1 Prospective Adoptive Parent

Birth Date

Birth Place

City State / Province / Region

Are you adopted?

Current Age

US Citizen

Languages Spoken

Length of Residency in Current State

If naturalized, give place, date, and certificate number?

Ap 2 Prospective Adoptive Parent

Birth Date

Birth Place

City State / Province / Region

Are you adopted?

Current Age

US Citizen?

Languages Spoken

Length of Residency in Current State

If naturalized, give place, date, and certificate number?

PHYSICAL INFORMATION

Ap 1 Prospective Adoptive Parent

Height

Weight

Eyes

Hair

Personality

Race

Ancestry/ Heritage

Ap 2 Prospective Adoptive Parent

Height

Weight

Eyes

Hair

Personality

Race

Ancestry/Heritage

Ap 1 and Ap 2 Prospective Adoptive Parents

If Native American, which tribe?

EDUCATION

Ap 1 Prospective Adoptive Parent

Highest grade completed

Location of high school

Year graduated or received GED

College & Location

Diploma

Degree

Date

Ap 2 Prospective Adoptive Parent

Highest Grade Completed

Location of high school

Year graduated or received GED?

College & Location

Diploma

Degree

Date

Previous Marriages and/or Annulments (if applicable)

Ap 1 Prospective Adoptive Parent

Former Spouse's Name #1

First Last

Date

Date Terminated

Children and their DOB

Former Spouse's Name #2

First Last

Date

Date Terminated

Children and their DOB

Former Spouse's Name #3

First Last

Date

Date Terminated

Children and their DOB

Ap 2 Prospective Adoptive Parent

Former Spouse's Name #1

First Last

Date

Date Terminated

Children and their DOB

Former Spouse's Name #2

First Last

Date

Date Terminated

Children and their DOB

Former Spouse's Name #3

First Last

Date

Date Terminated

Children and their DOB

ADDITIONAL INFORMATION

Ap 1 Prospective Adoptive Parent

Ap 2 Prospective Adoptive Parent

Religion Affiliation 1

Religion Affiliation

Military Service 1

Military Service

RESIDENCY

List the states/countries you have lived in since 18 years of age. List each state/country along with length of time you lived within each state/country.

Ap 1 Prospective Adoptive Parent

Ap 2 Prospective Adoptive Parent

AP 1 State/Country

State/Country

Dates lived in State

AP 2 State/Country

State/Country

Dates lived in State

If you need additional space, please write it here

*Previous Addresses (for last (10) years):

*Complete section, ONLY if you have not lived at current address for the last (10) ten years.

Ap 1 Prospective Adoptive Parent

AP 1 Prev Address

Dates Lived at this Address

Address

Ap 2 Prospective Adoptive Parent

AP2 Prev Address

Dates Lived at this Address

Address

Notes: Additional Address lived in over last 10 years (Dates and Who Lived There)

Work History (Last five years, beginning with most recent)

Ap 1 Prospective Adoptive Parent

List

Employer's Name

Address

Phone

Type of Work

Dates of Employment

Reason for Living

Ap 2 Prospective Adoptive Parent

List

Employer's Name

Address

Phone

Type of Work

Dates of Employment

Reason for Living

Notes: Add additional employment over the last five years.

HEALTH

Ap 1 Prospective Adoptive Parent

List medical issues for which you have needed treatment.

Have you had any hospitalizations?

Yes

Explain

Medications? List

Diagnosed with any mental health issues?

Name and full address of medical professional completing medical forms

Name

Address

Phone

Date of Physical Exam

Ap 2 Prospective Adoptive Parent

List medical issues for which you have needed treatment.

Have you had any hospitalizations?

Yes

Explain

Medications? List

Diagnosed with any mental health issues?

Name and full address of medical professional completing medical forms

Name

Address

Phone

Date of Physical Exam

Ap 2 Prospective Adoptive Parent

Have you or are you currently receiving infertility treatment? What was the diagnosis? What procedures have you tried? What procedures do you plan to pursue next?

CLEARANCE QUESTION

PROSPECTIVE ADOPTIVE PARENT (AP 1):

Please answer these questions truthfully and explain any "yes" responses on separate sheet of paper. Yes questions will not necessarily preclude approval of a home study, if sufficient rehabilitation has been established. Failure to disclose will preclude an approval of a home study. You will also have a chance to discuss/explain any "yes" answers during the home visit. Please select "Yes" or "No" for appropriate responses. Have you EVER:

Please select "Yes" or "No" for appropriate responses.

Have you EVER:

Received counseling or therapy?

Yes

Been treated for a mental illness?

Yes

Been treated for a major health condition(s)?

Yes

Been rejected or denied as a prospective adoptive parent?

Yes

Had a prior home study completed?

Yes

Begun a home study process in relation to an adoption or any form of foster or custodial care of a child that was uncompleted or unfavorable?

Yes

Been determined by any court to be fully or partially mentally incapacitated?

Yes

Had parental rights restricted, deprived, relinquished, or terminated?

Yes

Lost legal guardianship due to failure to meet the responsibilities of legal guardians or for any other reason?

Yes

Transferred or received permanent custody of a child outside of the state/local authorities?

Yes

Been denied a petition to adopt a child from overseas or denied a Visa?

Yes

Had any arrest (even as a minor), conviction or felony or misdemeanor charges filed against you or had any other adverse criminal history, whether in the U.S. or abroad, even if the record of the arrest, conviction or other adverse criminal history has been expunged, sealed, pardoned, deferred, dismissed, or the subject of any other amelioration?

**If Yes, please get a certified final disposition from the court in the county where arrest occurred. The final disposition must include information from arrest to prove you served your sentence. If the court cannot provide any information, you must get a statement from the court saying no information is available. Then please provide a written statement in your own words giving details about the incident starting from what led up to the arrest to serving the sentence, and place the words "signed under penalty of perjury under U.S. law" and sign the letter (this is an additional task beyond the autobiography).

Are you currently under probation, parole, supervised release or other similar arrangement for any conviction?

Yes

Have you EVER, even if it did not result in an arrest or a conviction had a history whether in the U.S. or Abroad:

Do you have a history of alcohol, drug or substance abuse?

Yes

Do you have a history of child abuse, sexual abuse, neglect or child trafficking?

Yes

Do you have a history of family violence and/or domestic violence?

Yes

CLEARANCE QUESTIONS

PROSPECTIVE ADOPTIVE PARENTS (AP2)

Please select "Yes" or "No" for appropriate responses

Have you EVER:

Received counseling or therapy?

Yes

Been treated for mental illness?

Yes

Been treated for major health condition(s)?

Yes

Been rejected or denied as a prospective adoptive parent?

Yes

Had a prior home study completed?

Yes

Begun a home study process in relation to an adoption or any form of foster or custodial care of a child that was uncompleted or unfavorable?

Yes

Been determined by any court to be fully or partially mentally incapacitated?

Yes

Had parental rights restricted, deprived, relinquished, or terminated?

Yes

Lost legal guardianship due to failure to meet the responsibilities of legal guardians or for any other reason?

Yes

Transferred or received permanent custody of a child outside of the state/local authorities?

Yes

Been denied a petition to adopt a child from overseas or denied a Visa?

Yes

Are you currently under probation, parole, supervised release or other similar arrangement for any conviction?

Yes

Do you have a history of alcohol, drug or substance abuse?

Yes

Have you EVER, even if it did not result in an arrest or a conviction had a history whether in the U.S. or Abroad:

Do you have a history of child abuse, sexual abuse, neglect or child trafficking?

Yes

Do you have a history of family violence and/or domestic violence?

Yes

FAMILY HISTORY

Complete the following family history information to the best of your ability!

Ap 1 PROSPECTIVE ADOPTIVE PARENT:

Mother

FullName

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Education

Occupation (Prior to retirement)

Are they Retired?

Are they Supportive of your adoption plan?

Father

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Education

Occupation (Prior to retirement)

Are they Retired?

Are they supportive of your adoption plan?

If Applicable: Step-Father

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Occupation (Prior to Retirement)

Are they Retired

Are they supportive of your adoptive plan?

If Applicable: Step-Mother

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Occupation (Prior to retirement)

Are they retired?

Are they supportive of your adoption plan?

SIBLINGS: (That you have a relationship with) Complete the following family history information to the best of your ability!

Sibling # 1

Relationship

Name

First Last

State

City State

Age

Education of Sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children's

Gender

Age

Are they supportive of your adoption plan?

Sibling # 2

Relationship

Name

First Last

Address

City State

Age

Education of sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of your adoption plan?

Sibling # 3

Relationship

Full Name

First Last

Address

City State

Age

Education of sibling

Siblings Occupation

Marital Status

Name of Spouse

Spouse Occupation

Children

Gender

Ages

Are they supportive of your adoption plan?

Sibling # 4

Relationship

Full Name

First Last

Address

City State

Age

Education of sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of your adoption plan?

FAMILY HISTORY

Complete the following family history information to the best of your ability!

Ap2 PROSPECTIVE ADOPTIVE PARENT:

Mother

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Education

Occupation (Prior to retirement)

Are they supportive of your adoption plan?

Father

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Education

Occupation (Prior to Retirement)

Are they supportive of your adoption plan?

If Applicable: Step-Father

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Occupation (Prior to retirement)

Are they supportive of your adoption plan?

If Applicable: Step-Mother

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Nationality

Religion

If divorced, give date

If deceased, give date

Occupation (Prior to retirement)

Are they supportive of your adoption plan?

SIBLINGS: (That you have a relationship with) Complete the following family history information to the best of your ability!

Sibling # 1

Relation

Full Name

First Last

Address

City State

Age

Education of Sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of your adoption plan?

Sibling # 2

Relation

Full Name

First Last

Address

City State

Age

Education of Sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of your adoption plan?

Sibling # 3

Relation

Full Name

First Last

Address

City State

Age

Education of sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of your adoption plan?

Sibling # 4

Relation

Full Name

First Last

Address

City State

Age

Education of sibling

Sibling's Occupation

Marital Status

Name of Spouse

First Last

Spouse Occupation

Children

Gender

Age

Are they supportive of you adoption plan?

HOUSEHOLD MEMBERS: Children/Others

List ALL others living in your home including children, relatives, and/or boarders. (If there has been a death of a child, please indicate the age of death and cause.)

Full Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 2

Full Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 3

Full Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 4

Full Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 5

Full Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 6

Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

Household Member # 7

Name

First Last

Date of Birth

Relationship

Grade/Occupation

Have a Criminal History?

Yes

List Other children not living in the home (if child is adopted and lives in another country, submit copy of adoption order).

For ADULT children living outside the home please provide their phone number so we may talk with them as part of the home study process.

List

Full Name

Date of Birth

Relationship

Grade or Occupation

Phone Number for Adult Child (Required)

Pets

Domesticated Pets

List

Name

Age

Type of Pet (Dog, Cat, etc.)

Friendly?

Vaccinations Current?

GUARDIANSHIP INFORMATION:

It is a requirement to appoint a guardian for your adopted child in the event of your untimely death, debilitating accident, or illness. Try to choose guardians under the age of 55 (if older than 55 choose a 2nd set of guardians also) China guardians must be between 30-55 years of age.

Name of Guardian(s)

Address

Relationship to your family

Why did you choose them as your guardian

Gender

Age

Profession

Health

Annual Salary (Required for China Adoption Only)

If Married, How Many Years Married

Number of Children in Household

Children

Gender

Age

PREVIOUS HOME STUDY

Have you ever had a previous home study process started?

Yes

Name of agency that started the previous home study process?

Date home study process began

Date home study process was completed

Did the home study recommend your family or other adult members of the household?

Yes

If no, please explain

If the home study process was incomplete, what date did the home study process end, and the reason?

Have you ever been turned down for adoption by another agency?

Yes

If yes, explain

If you have adopted before, who facilitated your adoption?

~ NOTE: We will need a copy of all home study reports completed previously. ~

RESIDENCE

Type of construction (brick, siding etc.)

Style (ranch, colonial etc.)

Age of structure

Square feet of living area

Size lot

Date moved in

Appraised Value of Home

Equity in home

Amount still owed

Improvements or remodelling planned?

Please describe your neighborhood and community

Why do you live where you do?

Do you have any other properties?

Prior to the home visit, develop a fire evacuation plan and practice it. Place at least one smoke detector outside the bedrooms and on every level of the home. Have a carbon monoxide detector in the home and a fire extinguisher in the kitchen. A tour of your entire home will occur.

HOME

Please place an X to indicate the features your home has.

Interior

Kitchen

Dining Room

Living Room

Family Room

Bedrooms

Bathrooms

Office

Playroom

Bedrooms #

Full Bathrooms #

Partial Bathrooms #

Basement

None

Full

Partial

Finished

Unfinished

Window

Walkout

Windows #

Exterior

Fenced in backyard

Pool

Pond/Lake

Other:

Safety Features

Smoke Detectors

Carbon Monoxide Detectors

Fire Extinguishers

Fire Arms?

Others:

List Location of Smoke Detectors

List Carbon Monoxide Detector Locations:

List Fire Extinguisher Locations:

Fire Arms Safely Stored?

Others

Finances

Ap 1 Prospective Adoptive Parent

Current annual income

Previous year's annual income

Additional income sources (from)

Have you ever filed for bankruptcy?

Yes

If yes, please explain on a separate sheet of paper

Ap 2 Prospective Adoptive Parent

Current annual income

Previous year's annual income:

Additional income sources (from)

Have you ever filed for bankruptcy?

Yes

If yes, please explain on a separate sheet of paper

Assets:

Real Estate (Home): $

Other Real Estate: $

Stocks/Bonds: $

Retirement (401K, IRA): $

Savings Account(s): $

Checking Account(s): $

Money Markets, CD's: $

Annuities: $

Other Investments: $

Vehicle (Present Value): $

Vehicle #2: $

Personal Property: $

TOTAL ASSETS: $

(Not including income or life insurance)

Liabilities:

Home Mortgage (Monthly Payments): $

Home Mortgage (Balance): $

Car Loan #1 (Monthly Payments): $

Car Loan #1 (Balance): $

Car Loan #2 (Monthly Payments): $

Car Loan #2 (Balance): $

Credit Card (Monthly Payments): $

Credit Card (Balance): $

Home Equity Loan (Monthly Payments): $

Home Equity Loan (Balance): $

Student Loans (Monthly Payments): $

Student Loans (Balance): $

Other Loans (Monthly Payments): $

Other Loans (Balance): $

TOTAL LIABILITES: $

NET WORTH: $

Total Assets minus Total Liabilities

BUDGET:

Giving/Tithes: $

Telephone/Cell: $

Insurance(s): $

Credit Card: $

School Expenses: $

Misc. : $

Child Support: $

If applicable, are you current on support payments?

Yes

If no, please explain

Mortgage/Rent: $

Car Payment: $

Food: $

Clothing: $

Medical: $

Utilities (water, gas, etc.): $

Gasoline: $

Childcare: $

Entertainment: $

Other Loans: $

TOTAL INCOME Per Month: $

TOTAL EXPENSES Per Month: $

Describe your plans to become debt free (if not already):

Describe how you plan to pay/finance your adoption

Do you anticipate changes in your financial situation?

AUTHORIZATION AND ACKNOWLEDGMENT

I have read all instructional material in this form and have completed it to the best of my ability. I also state that I have read and understand the requirements and procedures defined by Adoption & Beyond. I hereby certify by my signature below that the foregoing application information and my statements therein are correct and true and understand that falsified statements on this or subsequent paperwork or contact, both written and/or verbal shall be grounds for termination of services. In addition, withholding and/or providing misleading information shall also be grounds for termination of services.

I understand this Application for Adoption is a vital tool in completing my home study assessment. Partial completion of this document or refusal to submit this or any other required or requested documentation may result in the termination of home study services or a non-approval of my home study.

Adoption & Beyond and its representatives assume no responsibilities and will not be held liable for the statements, acts or failure to act by any other entity including but not limited to birth parents, attorneys, doctors, government agencies, orphanages, public officials and/or other child placing entities.

I have read and understand all of the above and the information I have provided is true and accurate:

Signature of Prospective Adoptive Parent

Date

Signature of Prospective Adoptive Parent

Date

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