REFERENCE

FAMILY'S NAME(Required)

YOUR NAME(Required)

First Last

Phone Number(Required)

Email(Required)

Address(Required)

City State / Province / Region ZIP / Postal Code Country

The above named family is applying for adoption and they have chosen you to serve as a reference for this important process. The adoption process and the raising of children often involve stress, patience, extensive teamwork as well as restrictions on personal freedom. Because of these factors, we would appreciate your objective input for this family's ability to pursue the adoption process.

How long have you known this family?

In what relationship have you known this family?

What is the name of the Prospective Adoptive Parent #1?

How well you know prospective parent #1

What is the name of the second Prospective Adoptive Parent?

First Last

How well you know prospective parent #2

What are your reasons for recommending this family to adopt? Include specifics on this family's ability to parent?

Describe the family's personalities, character, level of maturity, community relations and interpersonal relationships. Add any knowledge you have about the family's mental health.

Describe the atmosphere and stability of the family's home and their marital relationship (if applicable).

Your overall recommendation regarding this family as a prospective adoptive parent

If you have noted a concern, have you discussed this concern with the family?

Yes

List any reason you do not feel this family is suitable to adopt.

Date

Signature

REFERENCE

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