Therapist Questionnaire

The client listed below has applied for service through Adoption & Beyond, Inc. *If a client is receiving or has received therapy, we require that we receive the opinion of a licensed therapist about the applicant’s suitability for adoption based strictly on the therapy received from you. The information provided will be noted in the client’s home study report to the extent necessary.

Please answer all of the questions in the General section and then all of the questions in any other section that may apply to this client. We appreciate your input, you may answer on this form or you may write a separate letter, which addresses all applicable questions. Please return this form or a letter completed and signed to Adoption & Beyond, Inc. 16236 Metcalf Ave., Overland Park, Kansas 66085, with a business card attached or email to homestudy@adoption-beyond.org or fax to 913-381-6909. Please contact us with any questions 913-381-6919.

Applicant Name(s)(Required)

Name

Phone(Required)

Email(Required)

GENERAL QUESTIONS

How long have you known this client?

Approximate number of visits with client

Time period during which visits have occurred

What issues did the client present at time of initial meeting?

Diagnosis of client:

In your opinion, will the client’s mental, emotional or psychological health in any way interfere with their ability to be an adoptive parent?

If applicable, please be specific about the type of child that you believe would not be appropriate for this client to parent.

QUESTIONS FOR CLIENTS ON MEDICATION

Please list all psychotropic medications you are aware of taken by client, even if prescribed by another health care provider.

To the best of your knowledge, do you consider the client to have been stable on and compliant with all medications as of the date of your last visit?

Yes

If no, please elaborate.

If yes, for how long?

What is your opinion of the risk that this client will become non-compliant?

Very Low

Low

Moderate

High

Very High

QUESTIONS FOR CLIENTS WHO HAVE SUFFERED FROM ABUSE (CHILDHOOD OR ADULT), OR AS THE FAMILY MEMBER OF A SUBSTANCE ABUSER OR MENTALLY ILL PERSON.

Please check the box the type(s) of abuse the client suffered:

Physical

Sexual

Emotional

Neglect

Abandonment

Raised With Substance Abuser(s)

Raised With Mentally Ill Family Member(s)

Domestic Violence

Other (describe)

Describe the nature, length, approximate dates, and severity of the situations listed previously:

In your opinion, has the client adequately addressed the life issues caused by the situation(s) noted above? Please describe efforts made:

QUESTIONS FOR CLIENTS WITH A PERSONAL HISTORY OF SUBSTANCE ABUSE

What is your understanding of the client’s history of substance abuse, including drug of choice, length of abuse/addiction, contact with justice system, rehab attempts, etc.?

In your opinion, is this client currently clean and sober?

Yes

If yes, for how long?

Please provide your opinion regarding the risk that this client will relapse into substance abuse.

Very Low

Low

Moderate

High

Very High

In your opinion, will the risk of relapse be significantly increased by the stress of adopting children with emotional/behavioral problems or special needs?

Yes

If yes, please be specific about appropriate limitations for this client:

QUESTIONS FOR CLIENTS WITH HISTORY OF VIOLENT BEHAVIOR

What is your understanding of the client’s history of violent behavior, including initial manifestation of problem, duration of problem, contact with justice system, participation in therapy, etc.?

In your opinion, is this client currently abstaining from violent behavior?

Yes

If yes, for how long?

Please provide your opinion regarding the risk that this client will relapse into violent behavior.

Very Low

Low

Moderate

High

Very High

In your opinion, will the risk of relapse be significantly increased by the stress of adopting children with emotional/behavioral problems, or special needs?

Yes

Please be specific about appropriate limitations this client, including identification of any type of children not recommended for placement with this client:

QUESTIONS FOR CLIENTS WITH MULTIPLE MARRIAGES/RELATIONSHIPS OR RECENT RECONCILIATION AFTER SEPARATION

What is your understanding of the number of marriages/significant relationships for this client?

What is your opinion of the stability of the client’s current marriage?

What are the issues, in your opinion, which contributed to this client’s multiple broken relationships or any recent separation with reconciliation?

In your opinion, has the client adequately addressed those issues in such a way as to significantly improve the likelihood of remaining married to the current spouse? Please explain your answer.

QUESTIONS FOR CLIENTS WITH INFERTILITY ISSUES

What is your understanding of this client’s history of infertility, including number of years attempting to conceive, medical procedures, number of lost pregnancies and date of last pregnancy/miscarriage?

In your opinion, has this client worked through the emotions relating to the infertility, such as anger, depression, grieving, so that adoption is now an appropriate choice? Please explain your answer.

(FOR ALL CLIENTS) THERAPIST’S RECOMMENDATION AND ADDITIONAL COMMENTS

*Reminder it is a requirement that we receive the opinion of a licensed therapist about the applicant’s suitability for adoption based strictly on the therapy they received from you.

Therapist Signature(Required)

Date(Required)

Print Name and License Number

Address

Street, City, and State

Telephone Number

GENERAL QUESTIONS

QUESTIONS FOR CLIENTS ON MEDICATION

QUESTIONS FOR CLIENTS WHO HAVE SUFFERED FROM ABUSE (CHILDHOOD OR ADULT), OR AS THE FAMILY MEMBER OF A SUBSTANCE ABUSER OR MENTALLY ILL PERSON.

QUESTIONS FOR CLIENTS WITH A PERSONAL HISTORY OF SUBSTANCE ABUSE

QUESTIONS FOR CLIENTS WITH HISTORY OF VIOLENT BEHAVIOR

QUESTIONS FOR CLIENTS WITH MULTIPLE MARRIAGES/RELATIONSHIPS OR RECENT RECONCILIATION AFTER SEPARATION

QUESTIONS FOR CLIENTS WITH INFERTILITY ISSUES

(FOR ALL CLIENTS) THERAPIST’S RECOMMENDATION AND ADDITIONAL COMMENTS

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