1. In the states of Kansas and Missouri, it is required that accurate social history information is provided to the courts and to the adopting parents. Therefore, these forms were developed in order for you to provide accurate and honest background and health information to all parties involved in the adoption process.
2. Your goal is to find adoptive parents who are well-equipped to raise your child. There’s no point in withholding important information. Everyone has issues and there is a family out there who will embrace yours.
3. Final note: this information will also be valuable to your child as they grow. We hope you will continue to be available to provide this information but, if for some reason you are not, your child will benefit from this document.
BACKGROUND INFORMATION
SOCIAL HISTORY REPORT OF PROSPECTIVE BIRTH FATHER
Name of Friend or Relative who would be able to contact you in the future:
NATIVE AMERICAN
(THIS INFORMATION IS IMPORTANT IN COMPLYING WITH THE INDIAN CHILD WELFARE ACT WHICH CAN IMPACT THE ADOPTION PROCESS)
If you have any Native American Indian Heritage in your family’s background, please list the following:
Please list the full name, birth date, blood percentage, and tribal enrollment number of your family members who also have Indian Heritage and state whether the person is on your maternal or paternal side of the family.
RELIGION
EMPLOYMENT
Please list your past and present employment history (within the last 2 years):
INCOME
ARMED FORCES
CRIMINAL BACKGROUND
*Criminal checks performed when necessary
EDUCATION
High School/GED
College
Other Educational Information
Looking at your entire educational career, please state the following:
Please list the following regarding yourself:
Please answer the following questions about yourself
FAMILY HISTORY
It is very important that you are as thorough as possible in providing information about your biological parents:
PLEASE STATE THE FOLLOWING:
SIBLING HISTORY
Please list information about all of your siblings. Please be as thorough as possible:
Sibling History
CHILDREN
Children
MARITAL STATUS
IF CHILD IS ALREADY BORN
RELATIONSHIP
ADOPTION INFORMATION
ex. Be there during labor/delivery, meet the family, be there when she signs relinquishment papers?
ex. photos, letters, phone calls, text, gifts, face-to-face meetings, etc.
Commitment to Adoption:
AFFIRMATION OF ACCURACY
I understand that in the states of Kansas and Missouri it is a requirement that accurate social history information is provided to the Courts and to the adoptive parent(s). Therefore, by completing these forms, I affirm that the background and health information that I have provided in this Social History Document is accurate to the best of my knowledge and will be shared with the courts, attorneys and adopting family. I acknowledge that I have been given the agencies Grievance Procedure and Form.
I understand that this information will be made available to my child. I also understand that the information about one's birth heritage is valuable to one’s health and self-awareness. Therefore, I understand the importance of providing continued updated information as my child grows.
Written Oath
By signing this document I do solemnly swear that the statements in this document are true to the best of my knowledge and belief, so help me God.
Respectfully Signed and Submitted,
RELEASE OF INFORMATION
I am meeting with Adoption & Beyond, Inc., an agency that specializes in child placement services, in order to discuss and provide information that is required by state statute in an adoption.
I am sharing personal information about myself and my family (family background history, medical and genetic information, family relationships, etc.). I am also discussing my reasons for possibly placing my child for adoption, the relationship with the other potential birth parent(s), whether my decision is voluntary, and details of any adoption plan being made with prospective adoptive parent(s) and any agent of theirs.
I understand that the information that is provided to Adoption & Beyond, Inc. in regards to the adoption plan may be subject to confirmation and disclosure to all parties involved in the adoption process, including, but not limited to, attorneys, the prospective adoptive parent(s), and any agent of the above. I understand that information provided will be released to the attorneys involved in the adoption plan, the prospective adoptive parent(s) and to the Courts hearing the adoption. In some cases, some details may be discussed with the appropriate social service staff at the hospital where the baby is born or planned to be delivered or with other adoption professionals.
I hereby authorize and consent Adoption & Beyond, Inc., to communicate with any professional connected to this case and/or individual who would have knowledge about my past and/or present life circumstances in order for the agency to work with me effectively. I understand that information shared with the agency in planning for an adoption will not be held in confidence.
I understand all of the above and my signature below hereby gives Adoption & Beyond, Inc. the authority to release information regarding my case to appropriate parties specific to this case and for other professionals to share information with Adoption & Beyond regarding my case.
Signed,
Prospective Birth Father Signature