| From Where You Sit |
| Is there anything you would like to share about yourself or the child/children you seek to adopt? |
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| If possible, please indicate what is most important at this time in your adoption planning (e.g. time frame, amount of information, cost, age of child/children, health of child/children, travel requirements, etc.) |
| Is there anything you would like to share about yourself or the child/children you seek to adopt? |
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| Health History |
Managing an emotional or mental health issue is not a deterrent to adoption. If you have a mental or emotional diagnosis, please secure a letter from your doctor advising of your ability to parent a child with your therapeutic protocol highlighted.
We thank you for your honest responses to this questionnaire. Your answers will be held in confidence by the owner of ASA and will only be shared with an adoption professional if this information is requested. |
| Has Ap 1 had any significant medical or mental health condition? |
Yes No * |
| If yes, please provide a details explaining your diagnosis, prognosis, treatment, life expectancy and its potential effect on your ability to parent a child |
| * |
| Ap1, have you ever been in counseling/therapy for yourself or for a family member? |
Yes No |
| If yes, can you give length of time you or your family member received services: |
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| Ap 1, have you ever been evaluated by a mental health professional? |
Yes No |
| If yes, when was your last evaluation? |
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| Ap 1, if you are currently under a mental health clinician's care (i.e. psychiatrist, psychologist, therapist, counselor), please state the reason for your ongoing treatment: |
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| Ap 1, are you prescribed any medication for emotional or mental health? |
Yes No |
| If yes, please list your medications: |
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| Has Ap 2 had any significant medical or mental health condition? |
Yes No * |
| If Yes, please provide a details explaining your diagnosis, prognosis, treatment, life expectancy and its potential effect on your ability to parent a child |
| * |
| Ap 2, have you ever been in counseling/therapy for yourself or for a family member? |
Yes No |
| If yes, can you give length of time you or your family received services: |
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| Ap 2, have you ever been evaluated by a mental health professional? |
Yes No |
| If yes, when was your last evaluation? |
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| Ap 2, if you are currently under a mental health clinician's care (i.e. psychiatrist, psychologist, therapist, counselor), please state the reason for your ongoing treatment: |
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| Ap 2, are you prescribed any medication for emotional or mental health? |
Yes No |
| If yes, please list your medications: |
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| Type of Adoption |
Full Open Adoption: Willing to communicate directly with a birth family through letters, pictures, phone calls, and possible visits; willing to give your last name and place of residence.
Semi-Open Adoption: Willing to communicate with the birth family through the agency by sending pictures of your child to the birth family via the agency without revealing any identifying information.
Closed Adoption: NO communication with the birth family, thus closing the door for future medical history.
Check one or all that apply. |
| Type of Adoption |
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