Adoption Paperwork for Placing an Older Child

Providing the Support You Need In Choosing Your Child's Future

Confidentiality Statement
All information you share with us is completely confidential.
We only use this information to assist you in learning more about adoption for your specific situation.

Confidential Adoption Information Questionnaire
for placing an older child for adoption

Please complete as much of this form as you feel comfortable with. Completing this form does not require that you complete an adoption plan. It enables us to better help you in your unique situation.

First, The Basics…
Your Full Name
Your Address
City
State
Zip code
Phone number
Cell phone number
Email address
Confidential?	Yes No
May we leave a message?	Yes No
U.S. Citizen?	Yes No
Your Date of Birth
Your race:
Your ancestry:
Your religious preference:
Employer and occupation:
How did you hear about Lifetime?
About Your Child...
Child's name:
Child's birth date:
Child's sex:	Boy Girl
Height:
Weight:
Hair color:
Eye color:
Your child's race:
Grade in school:
Is your child currently living with you?	Yes No
If no, please explain:
Has your child ever tried to...
Light a fire?	Yes No
Harm another child?	Yes No
Harm an animal?	Yes No
If yes to any of these questions, please explain:
What are you child's interests/hobbies?
Please describe your child's typical daily routine at this time:
Why are you seeking to create an adoption plan at this time?
When You Were Pregnant With this Child...
Did you smoke cigarettes?	Yes No
How much? When?
Used Alcohol?	Yes No
How much? When?
Used Drugs?	Yes No
How much? When?
Did you have a normal pregnancy and delivery with this child? Please list any complications::
Health Background Please share with us any health issues that you, your baby’s father, or your families may have.
About Your Adoption Plan…
What type of adoptive family are you looking for?
Have you seen any families on the Lifetime website that you are interested in?	Yes No
If yes, what are your top three families?
If you desire ongoing contact after the adoption with the adoptive family, please describe your wishes:
Are you open to having counseling?	Yes No
Have you told your family about your intention to place your child for adoption?	Yes No
Are they supportive of your decision?	Yes No
Do you feel close to your mother?	Yes No
Is she supportive of your decision?	Yes No
Have you told any friends of your adoption plans?	Yes No
Are they supportive of your decision?	Yes No
What do you feel are the benefits of an open adoption?
What plans or goals do you have for the next 2 years (school, work, etc).
What plans or goals does the birth father have for the next 2 years?
What would it take for you to be able to parent your child yourself?
If there were anything that could influence you to change your mind and parent your child, what would it be?
Are you working, or have you worked with any other adoption center, agency, or lawyer in regard to the adoption of this child? If yes, please list which ones:
Your Child's Doctor
Name
City
State
Phone number
Last appointment:
Have you told your child's doctor that you plan to make an adoption plan?	Yes No
Would you be willing to allow Lifetime, and/or adoptive parents, to speak with your child's doctor?	Yes No
Is your child current on all recommended vaccinations?	Yes No
On track developmentally?	Yes No
If no, please explain:
Please explain in detail any health and/or behavioral problems:
Native American Heritage
Do either you or the child's father have any American Indian relatives, or are you of Native American heritage?	Yes No
If yes, please share the name of tribe::
About the Father of Your Baby…
His Name
His Address
City
State
Zip code
Phone number
Cell phone number
U.S. Citizen?	Yes No
His Age or Date of Birth
Does he work? If so, what does he do?
Hair Color?
Eye Color?
Complexion?
Height?
His Race?
Are you married to the father of this child?	Yes No
Has he helped you financially (child support)?	Yes No
Does he know you’re considering adoption?	Yes No
Is he willing to agree to the adoption, and to sign the necessary legal papers?	Yes No
Does he wish to meet the adoptive parents?	Yes No
Have you lived with him?	Yes No
Has he acknowledged the child is his?	Yes No
Does he have other children?	Yes No
Does he have a history of drug use?	Yes No
Has he been arrested?	Yes No
If yes, please explain...
Do you believe he is willing to agree to the adoption and sign the necessary legal papers?	Yes No
Marriages & Children
Are you presently, or have you ever been married?
Name of husband:
Address:
Phone:
Date and place of marriage:
Date and place of divorce:
Date and place of separation:
Do you have any other children?
Name(s) and date(s) of their birth:
With whom do the children live?
Have you ever placed any other children for adoption?
Were you or any member of your family adopted?

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