ࡱ> y bjbjcc   f f"BB8 <\!$6L0#(####:''4(KKKKKKK$fORpK,(&@'",(,(K##K+++,(j##K+,(K++2DG#Le(6oF.KL06LFNR)6R\GRG,(,(+,(,(,(,(,(KK+,(,(,(6L,(,(,(,(R,(,(,(,(,(,(,(,(,(BX : **Please note this application is for families living in Oklahoma pursuing an adoption home study ONLY. For families looking to use ACO as a placing agency, please complete the placing agency application. ** Please note that no work will begin on the home study until payment is received. First Applicants full name (including maiden, if applicable): _______________________________ _____________________________________________________________________________________ Second Applicants full name (including maiden, if applicable): ____________________________ _____________________________________________________________________________________ Home address: ______________________________________________________________________ Home telephone number: (____)________________________________________________________ First Applicants cell/mobile number: (____)_______________ E-mail:_______________________ Second Applicants cell/mobile number: (____)_________________ E-mail:___________________ Home fax number: (_____)_____________________________________________________________ Date and place of marriage: ___________________________________________________________ Names and birth dates of children of this marriage. State whether adopted or biological. _____________________________________________________________________________________ Who referred you to us? ______________________________________________________________ PERSONAL INFORMATION FIRST APPLICANT: Age; date of birth; birthplace ______________________________________ _____________________________________________________________________________________ Social Security No.: ___________________________________________________________________ Race/Nationality: ____________________________________________________________________ Weight and Height: __________________________________________________________________ Education: ___________________________________________________________________________ Occupation: _________________________________________________________________________ Employer: __________________________________________________________________________ How long? __________________________________________________________________________ Office address: ______________________________________________________________________ Office telephone: _____________________________ Fax ___________________________________ Office e-mail: ________________________________________________________________________ Annual income: _____________________________________________________________________ Religious preference: _________________________________________________________________ Dates of previous marriages and divorces: _______________________________________________ Children by previous marriages: (ages and custody status) ________________________________ _____________________________________________________________________________________ SECOND APPLICANT: Age, date of birthplace : _______________________________________ ____________________________________________________________________________________ Social Security No.: ___________________________________________________________________ Race/Nationality: ____________________________________________________________________ Weight and Height: __________________________________________________________________ Education: ___________________________________________________________________________ Occupation: _________________________________________________________________________ Employer: __________________________________________________________________________ How long? __________________________________________________________________________ Office address: ______________________________________________________________________ Office telephone: _____________________________ Fax ___________________________________ Office e-mail: ________________________________________________________________________ Annual income: _____________________________________________________________________ Religious preference: _________________________________________________________________ Dates of previous marriages and divorces: _______________________________________________ Children by previous marriages: (ages and custody status) ________________________________ _____________________________________________________________________________________ OTHER HOUSEHOLD MEMBERS: Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ ADULT CHILDREN WHO NO LONGER LIVE IN THE HOUSE: Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ Telephone number: ___________________________________________________________________ Name: ______________________________________________Birthdate:_______________________ Relationship _________________________________________Birthplace:______________________ Telephone number: ___________________________________________________________________ Name: _____________________________________________Birthdate:_______________________ Relationship ________________________________________Birthplace:_______________________ Telephone number: ___________________________________________________________________ FAMILY BACKGROUND FIRST APPLICANT: Fathers name: ___________________________________________________ Address: ____________________________________________________________________________ Phone number: _______________________________________________________________________ Age and occupation: ___________________________Birthdate/Birthplace___________________ If deceased, year and cause of death_____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Mothers name: ____________________________________________________________________ Address: ____________________________________________________________________________ Phone number: _______________________________________________________________________ Age and occupation: ________________________Birthdate/Birthplace______________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Brothers and/or sisters: Name: ________________________________________________________ Address: ____________________________________________________________________________ Phone number: __________________________________Birth date/Birthplace_________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year _____________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: _____________________________Birth date/birthplace______________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: __________________________Birth date/birthplace_________________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ___________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: __________________________________Birthdate/birthplace__________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ SECOND APPLICANT: Fathers name: ___________________________________________________ Address: ____________________________________________________________________________ Phone number: _______________________________________________________________________ Age and occupation: ________________________Birthdate/birthplace______________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Mothers name: _____________________________________________________________________ Address: ____________________________________________________________________________ Phone number: _______________________________________________________________________ Age and occupation: ________________________Birthdate/birthplace_______________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Brothers and/or sisters: Name: ________________________________________________________ Address: ____________________________________________________________________________ Phone number: __________________________________Birth date/birthplace_________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: ___________________________________birthdate/birthplace_________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year _____________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: __________________________________birth date/birthplace_________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: _____________________________Birthdate/birthplac_______________________ Age and occupation: _________________________________________________________________ Marital status and spouses name: ______________________________________________________ Names and ages of children: __________________________________________________________ _____________________________________________________________________________________ If deceased, year and cause of death ____________________________________________________ High School graduate? Yes________ No_______ If yes, name of school and graduation year ______________________________________________ College graduate? Yes_____ No_____ If yes, name of school and graduation year ______________________________________________ MEDICAL PROBLEMS: PAST OR PRESENT First Applicant: ______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ Medical marijuana card: Yes_____ No_____ (if yes, please provide copy) Second Applicant: ____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ Medical marijuana card: Yes_____ No_____ (if yes, please provide copy) SUBSTANCE ABUSE Has either applicant been in treatment (outpatient or in-patient) for substance abuse? If yes, please explain. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Has either applicant been diagnosed with a drug or alcohol addiction? If yes, please explain. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Does either applicant smoke, vape, or use any recreational drugs (legal or not legal)? If yes, please explain. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ REFERENCES Please list three references of NON-RELATIVES who have written letters on your behalf. It if preferable that the references have known you as a couple for at least three year. Please also enclose the letters. It is the policy of our agency to call these references to verify that the individual(s) actually wrote the letters. Letters must be signed, dated and have phone number and address. Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: ______________________________________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: ______________________________________________________________________ Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: ______________________________________________________________________ PREPARATION FOR ADOPTION Why are you choosing adoption? _______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you had an adoption fail or fall through? If so, briefly describe the circumstances. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you had a home study conducted by anyone for adoption purposes? If so, who conducted it and when? Please enclose a copy if you were given one. _________________________________ __________________________________________________________________________________________________________________________________________________________________________ Have you ever been denied a favorable home study? If so, when? __________________________ What has your family done to prepare for adoption (classes, books, support group, changes in the home, etc) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If you have had a previous adoption, please describe the process and how your family adapted _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What is your plan to help your child understand adoption? ________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What are your attitudes towards birth parents? __________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What are your attitudes and expectations to openness and to the child pursing his/her birth family or asking questions about them? _________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ INFORMATION ON CHILD YOU WISH TO ADOPT Sex and age preference: _______________________________________________________________ Would you accept twins? _____________________________________________________________ Nationality you would accept: Caucasian: ________ Marshall Islands: ________ Hispanic: ________ Hispanic mix: ________ African American: ________ African American mix: ________ Asian/Oriental: ________ Asian/Oriental mix: ________ Hawaiian: ________ Hawaiian mix; ________ Other: ________________________________________________________ Are either of you enrolled or eligible for enrollment in any Indian Tribe? What Tribe? __________________________________________________________________________________________________________________________________________________________________________ Would you accept: An older child? __________ To what age? _______________________________________ More than one older child if siblings? ____________________________________________ A child with a correctable medical condition? _____________________________________ A child with a cleft lip/cleft palate? ______________________________________________ A child with a non-correctable medical condition? _________________________________ If yes, please explain any limitations: ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Would you accept a child whose biological parents: Has ever been drug addicted? Yes _______ No ________ Case by case ___________ Has used drugs recreationally throughout the pregnancy? Yes ______ No ________ Case by case ___________ Had used drugs before realizing she was pregnant? Yes _____ No ________ Case by case _______ Has ever been alcohol addicted? Yes _____ No _______ Case by case ________ Has used alcohol recreationally throughout the pregnancy? Yes _____ No _______ Case by case ________ Had used alcohol before realizing she was pregnant? Yes _____ No ________ Case by case ________ Had mental illness? Yes _____ No _____ Case by case __________ Whose parent(s) had mental illness? Yes _____ No _____ Case by case __________ What type of adoption are you willing to accept (open, semi-open, closed)? Check all that apply Open _________ Semi open ________ Closed _________ Describe the type of relationship you would like with the birth parents. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ YOUR HOME Do you own or rent your home? _______________________________________________________ If own, value of home: ________________________________________________________________ Mortgage left on home: _______________________________________________________________ Smoking allowed in the home?_________________________________________________________ Pets: Type:_________________________Breed:_____________________________Sex/age:___________ Type:_________________________Breed:_____________________________Sex/age:___________ Type:_________________________Breed:_____________________________Sex/age:___________ Type:_________________________Breed:_____________________________Sex/age:___________ Weapons: Type:_______________________________________________________________________________ Type:_______________________________________________________________________________ Type:_______________________________________________________________________________ FINANCES Do you have health insurance? If so, with what company. ________________________________ Life insurance? How much? __________________________________________________________ _____________________________________________________________________________________ Have you filed taxes the last three years? ________________________________________________ GENERAL QUESTIONS Have you ever been arrested, or do you have any type of criminal record? If yes, please explain: (You will be required to submit FBI fingerprints, OSBI reports or any state you have lived in for the last five years and Child Abuse Registry for Oklahoma or any state you have lived in for the last five years. Finally, 911 checks on your residences for the last five years will be conducted and/or OSCN checks on your person) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any other comments or information you would like to add: _______________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please initial the following: _______/_______We understand and acknowledge that the adoptive home assessment is an objective process, and that a positive assessment is not guaranteed. _______/_______ We understand that during the course of the home study, more information and documents may be requested of either applicant or family member. Any delay in turning these documents over to the home study provider will result in a delay of the home study process. _______/______ We understand that failure to disclose, lying, or concealing information can be cause for immediate cessation and/or denial of a home study. SIGNATURES: ________________________________________ _______________________________________ First Applicant Date ________________________________________ _______________________________________ Second Applicant Date Copyright ( 2015 Adoption Choices, Inc. This document is the property of Adoption Choices, Inc. Duplication, publication or decimation of this document in whole or in part is strictly prohibited without the express written permission of Adoption Choices, Inc. DOCUMENTS NEEDED TO COMPLETE HOME STUDY The following documents will be needed in order to complete your home study through our agency. Asterisks indicate those documents that will need to be copied and attached to the study. 1. Birth certificate(s)2. *Financial statement3. Divorce decree from previous marriages (if applicable)4. Current CPR training 5. Income tax returns for last three years (first page only)6. Verification of income and current employment history (letter from employer) 7. Copy of Indian heritage enrollment card (if applicable)8. Marriage license9. Verification of medical insurance under which child will be covered 10. *Current physicians report (for all household members)11. *Three reference letters from NON-RELATED persons who can address your suitability to adopt (with signatures, dates, addresses & telephone numbers) 12. *State Bureau of Investigation criminal history investigation, including fingerprints and Sex Offender Registry as applicable (for all household members 18-years-old and older) and CANIS clearance13. *Drivers License14. *Social Security Card15. *Medical Insurance card/medical marijuana card16. *Pet Vaccinations17. Reference Letters from Adult Children18. Verification of Life insurance coverage of $21,00019. Current Car Insurance20. Personal Narratives of each adoptive parent21. 10 hours of approved adoption training For your convenience, we have provided a column on the right-hand side of the page so you can check off the items you are providing to our agency. If you have any questions about the requested documents, please call our office at 405-794-7500, or email us at  HYPERLINK "mailto:info@adoptionchoicesofoklahoma.org" info@adoptionchoicesofoklahoma.org. Copyright 2015 Adoption Choices, Inc. This document is the property of Adoption Choices, Inc. Duplication, publication or decimation of this document in whole or in part is strictly prohibited without the express written permission of Adoption Choices, Inc. Adoption Choices of Oklahoma Fee Agreement for Agency Services I/We_____________________________ hereby request the services of Adoption Choices of Oklahoma to perform a home study evaluation of our family for the purposes of domestic adoption, foster care, or guardianship placement of a child into my/our home, and to provide other services as may be described below. It is agreed that I/we will provide detailed family background information on all family members, will complete agency forms as required, and otherwise cooperate with the agency to collect sufficient information about my/our family to complete an evaluation. I/We will provide personal references and copies of needed documents, such as birth certificates, marriage licenses, divorce decrees, military discharge papers, medical evaluation, tax returns for the last three (3) years, and any other items which may be needed. Providing false or inaccurate information may be cause for the agency to discontinue the home study process. I/We understand that the contract must be received to the home study provider before a date for the home visit can be set. All documentation must be provided to our social worker by the time of our first home visit. The home study will require at least one home visit with all members living in the home. Failure to provide all necessary documentation may result in delays and/or additional fees. The agency will complete a written report that will include the family background information, information about the child, and the agencys recommendation about the suitability of the applicants. It is understood that the placement recommendation is required by the court and will be based upon a professional assessment of the familys strengths and ability to provide a stable home environment for a child. I/We agree to hold agency harmless for the positive or negative evaluation that it may make and from any consequences that may result from such a recommendation. It is understood that the agreed upon charges for services are: Domestic home study 1,100.00 International home study 1,300.00 Domestic home study update 550.00 International update 750.00 Domestic post placement services 300.00/each visit/report International post placement services 400.00/each visit/report Other Services ______________ There is also an additional charge for expedited home studies as well as additional addendums that may be needed. For visits outside the Oklahoma City and/or Tulsa metro area, mileage of .55 cents a mile may apply. The application and fees are payable upon execution of the agreement unless other arrangement are made. It is understood that the fees are nonrefundable unless the agency cancels services without cause. I/We will reimburse agency for any agreed costs that the agency incurs on our behalf. Signatures: ____________________________________________ ____________________________________________ Date: ____________________________________________ ADOPTION CHOICES OF OKLAHOMA MEDICAL REPORT ON ADOPTIVE APPLICANTS AND ALL HOUSEHOLD MEMBERS First page to be filled out by applicant: Name: ____________________________________ Birthdate: _____________________________ Address: __________________________________ MEDICAL HISTORY: Have you had/have treatment for serious or chronic illness? Yes_____ No____ If yes, please explain: __________________________________________________________________________________________________________________________________ Have you been hospitalized in the last five years? Yes _____ No _____ If yes, please explain: __________________________________________________________________________________________________________________________________ Have you ever received or been advised to seek mental health services? Yes _____ No _____ If yes, please explain: __________________________________________________________________________________________________________________________________ Have you ever received or been advised to seek treatment for alcohol or substance abuse? Yes ______ No _____ If yes, please explain: __________________________________________________________________________________________________________________________________ Illnesses & Dates: __________________________________________________________ Operations & Dates: __________________________________________________________ Accidents: __________________________________________________________ Significant Family History (diabetes, heart disease, hereditary or congenital defects, etc.) Disease: _____________________________ Family member: _______________________________ Disease: _____________________________ Family member: _______________________________ Disease: _____________________________ Family member: _______________________________ Disease: _____________________________ Family member: _______________________________ Disease: _____________________________ Family member: _______________________________ Second page to be filled out by physician: PHYSICAL EXAMINATION: To the Physician: A physical examination is requested because this family is considering adoption/boarding a minor. Weight: _____________ Height: _____________ Blood Pressure: ______________________ Other exam findings: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Does this individual suffer from an illness, or communicable disease that would be detrimental to the care of an adoptive child placed in his/her home? Yes _____ No _____ If yes, please explain: __________________________________________________________ _____________________________________________________________________________ Are there any chronic or serious disorders for which this individual has received treatment? Yes _____ No _____ If yes, please explain: __________________________________________________________ Have you ever referred this individual to other medical services, mental health services and/or treatment for substance abuse? Yes ______ No ______ If yes, please explain: ___________________________________________________________ Impression of General Health (Does the patient have the usual expectancy of life?) Excellent ___________ Good (please state why)_______________________________________________________________ Fair (please state why)_________________________________________________________________ Poor (please state why)________________________________________________________________ Was any recommendation for medical care made to the patient? If so, state what: _____________________________________________________________________________________ Is patient on any current medication? If so, what and for what reason __________________________________________________________________________________________________________________________________________________________________________ Is this report based on a current examination only, or a longer professional relationship and knowledge? _________________________________________________________________________ If longer, how long have you been patients physician _____________________________________ Is this person physically and mentally a good candidate for adoption? If no, please explain why _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If physician has known patient personally or as a family physician, any comment he or she wishes to make would be welcome. _____________________________________________________ _____________________________________________________________________________________ Date of Exam: _________ Name and Address of Doctor: _______________________________ __________________________________________________________ STATEMENT OF GUARDIANSHIP We _____________________/________________________ hereby name _____________________________________and ____________________________________________ as guardians to our child(ren) in the event that we are no longer able to physically care and provide for them through both of our deaths. Names: ____________________________________________________________________________ Address: __________________________________________________________________________ Phone number: _____________________________________________________________________ Email: ____________________________________________________________________________ Relationship to us: ___________________________________________________________________ By our signatures, we acknowledge that the appointed guardians are aware of our decision and they have agreed to be named as guardians in this home study and as a part of the application process. Signed: ____________________________________________________________________________ Signed: ____________________________________________________________________________ Date:___________________________________ Witness: ________________________________ LETTER OF REFERENCE FROM NON-RELATIVE Dear Adoption Choices of Oklahoma: Please accept this completed questionnaire as a letter of reference for: _____________________ _______________________________________________________, prospective adoptive parent(s). 1. How long and in what capacity have you known the adoptive applicant(s)? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. How often do you see the applicant(s)? __________________________________________________________________________________________________________________________________________________________________________ 3. How would you describe the applicant(s)? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. What kind of parents do you think the applicant(s) will be and why? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. To your knowledge are there any physical or mental health problems that might be an issue? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. If the adopted child has special needs or is of a different race or culture, how do you think the adoptive parents will deal with these issues and how do you think the community will accept him or her? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 7. Do you have any other comments you would like to make? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. Do you recommend the adoptive applicant(s)? _______________________________________ _____________________________________________________________________________________ Signature(s) Date Please print your: Name(s): _________________________________________________________________ Address: _________________________________________________________________ Telephone: _________________________________________________________________ STATEMENT OF NET WORTH AND MONTHLY FINANCIAL OBLIGATIONS Name(s) _____________________________________________________________________________ ASSETS LIABILITIES Cash $____________ Mortgage /real estate $____________ Investments $____________ Notes payable $____________ Savings accounts $____________ Credit card (balances) $____________ Cash surrender value of life insurance $____________ $____________ Other stocks and bonds $____________ $____________ Real estate $____________ 1. $____________ Loans (balances) 2. $____________ _________________ $____________ Automobiles $____________ _________________ $____________ $____________ _________________ $____________ Trucks, boats, planes $____________ _________________ $____________ Personal property $____________ TOTAL ASSETS $____________ TOTAL LIABILITIES $____________ NET WORTH* $_______________________ (*Net worth is the difference between Assets and Liabilities) MONTHLY FINANCIAL OBLIGATIONS _______ Mortgage/Rent _______Car Payments _______Utilities _______Car Insurance _______Phone _______Other Insurances _______Credit Card Payments _______Student Loans _______Daycare _______Other Loans _______Investments _______Not listed Obligations _______Total MONTHLY INCOME _______________First Applicant _______________Second Applicant _______________Additional income (extra jobs, dividends, trust payments, settlements, etc) _______________Total  Guidelines for an Autobiographical Sketch INSTRUCTIONS: As you provide information about yourself, you will be assisting in the home study process. This will help us get to know you better and also speed up the procedure. Please write about the five main topics on the outline below. Use the questions within each section as suggestions for subjects you may wish to include as appropriate to your story. Feel free to add additional information that is significant in describing your life situation more completely. This information is for use by the home study specialist to prepare for your interviews. Three to six pages are usually adequate, but you may write as much as you wish. Please type. Thank you for taking the time to put this information together. Please type and double space your responses Tell about yourself and your childhood: How would you describe yourself as a person; what are you like; whats your personality? What was your life like in your family when you were a child? Describe briefly your relationship with any siblings, during childhood and now. What were your familys religious beliefs and practices? What did your family do for fun? Vacations, activities, etc. Describe your interests, talents, sports, clubs, school activities, etc.as a youth and Tell about your parents and how they raised you: Tell about your father (family background, education, work, etc.). Tell about your mother (family background, education, work, etc.). Describe your relationship with your parents, both during childhood and now. How did your parents discipline you? Who was the main disciplinarian? How often do you visit or spend time together? Tell about your marriage / relationship history: Describe past significant relationships (engagements, live-in relationships, divorces, etc.). Tell about your current marriage. What are your spouses best qualities? In what areas would you like to see your spouse or your relationship grow? Tell about your interest in adoption: Describe any experiences with infertility, fertility treatments, pregnancies, miscarriages, etc. Describe any previous attempts at adoption. What factors are causing you to consider adoption at this time? What does your family think of your plans to adopt? How would adoption impact or change your life? Describe your beliefs about parenting: Describe any experiences you have had parenting or caring for children. Describe your beliefs about parenting. What methods of discipline do you plan to use? To our prospective clients, As part of our ongoing commitment to the success of our adoptive families and our birth parents, we are requiring at least 10 hours of adoption education for our home study clients and our adoptive family applicants. We believe this is the best way to help our families understand the perspectives of our birth parents as well as begin their successful journey as an adoptive family. To our home study clients: As part of the home study process, our potential adoptive parents will be required to complete the following courses at  HYPERLINK "http://www.adoptiontrainingonline.com" www.adoptiontrainingonline.com: Multi-Cultural and Trans-racial adoption Openness in Adoption Our Child is Home! Now what? Bonding and Attachment Issues in Domestic Adoption Medical Risks for Domestically Adopted Children Each potential adoptive parent will be required to read the book Bridges Out of Poverty. This book is an excellent guide to help you understand and relate to our birth parents and will eventually help you to form better relationships during your match with them over time. Thank you for your understanding and cooperation in helping our agency provide the best service and outcomes to our birth parents and our adoptive families. Sincerely, Kirsten McGonigal, LMSW/MPH Child Placement Supervisor *Notes: The online training comes in two different options: The five courses are $15.00 per person, per course. There is the option of the Domestic Adoption Bundle. This bundle has 8 courses, of which the 5 required courses are included. The Domestic Bundle is $139.00 for couples Bridges out of Poverty can be purchased on Amazon for an average price of $20.00. I have found copies on Ebay and at Barnes and Noble as well. Finally, it is available for download on Goodreads and Audible.      PAGE \* MERGEFORMAT 2  ADOPTION INFORMATION/APPLICATION FOR ADOPTIVE HOME ASSESSMENT An Oklahoma Licensed Agency 201 N. 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