Application for Adoption Social Study, Certification Home Study or Re-Certification and other docs
In order to be able to complete the following application form accurately, you have to carefully read those instructions. Use the attached checklist to make sure you haven’t forgotten anything.
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REL ATIVE ADOPTION Rev. 3/2014
SUPERIOR COURT OF THE STATE OF ARIZONA
Pima County Juvenile Court
Adoptions & Guardianship Program
2225 EAST AJO WAY
TUCSON, ARIZONA 85713 -6295
520 -724-2920; 520 -724 -9239
FAX 520 -724 -4740 _________________________________________________________________________________________________________
Congratulations on your decision to adopt! The following steps outline t he procedures required to complete an adoption through
the PCJCC Adoptions Program. Please read all directions prior to filling out the packet . Keep this letter for your reference. If you
have any questions, please call Veronica at 740 -2920.
STEP 1: COMPLETE THE PACKET
Use the checklist on the next page to guide you in completing all necessary forms and obtaining copies of documents
before scheduling your fingerprint/document review appointment .
If this is an adoption by a step parent, the birth p arent married to the step parent must complete all the paperwork in the
packet as the second applicant .
Once you have completed the Document Checklist, call our office (520 -724 -2920) to schedule an appointment for
fingerprinting, packet review and fee paym ent.
STEP 2: FINGERPRINTING, PACKET REVIEW & FEE PAYMENT
Fingerprinting & Central Registry Records Check: Call our program (520 -724 -2920) to schedule an appointment to be fingerprinted
and sign a release for a central registry record check at the Pima County Juvenile Court Center, 2225 E. Ajo Way.
All persons 18 years of age or older living in the home, except the birthparent , must be fingerprinted. The fee for each
person fingerprinted is $22 .00, in the form of money order or cashier’s check, made payable to AZ DPS.
Fingerprinting is done by appointment only, and must be done in our office. Fingerprint results are usually returned to our
office four weeks after submission, but can take longer.
Packet Review: Bring your completed packet and required (original) documents to your fingerprinting appointment. We will make
copies of your original documents.
Fee Payment: Bring your adoption fee payment of $25 to the appointment. The payment can be in the form of personal check,
cashier’s che ck or money order, or Visa/MasterCard. Your fee will be paid to the Clerk of Superior Court.
Please note that the Adoption fee is to cover the cost to process your application for adoption and does not guarantee that
adoption will be recommended.
If a soc ial study is required to complete your adoption an additional fee will be required.
The fee is non -refundable , even if the adoption is delayed or denied. Our social worker can further discuss with you what
may cause an adoption to be delayed or denied.
Social Study Interview: Administrative orders allow for a social study to be conducted in certain situations.
After our office has received your fingerprint results and CPS Central Registry Check , we will review all information provided
and determine if a social study interview is applicable to your situation. If so, we will mail you an appointment letter wit h
the date and time of your Social Study Interview, which occurs in your home.
The home visit consists of a two hour (approximately) interview with our adoptions social worker. The petitioners for
adoption and the child(ren) to be adopted must be present for the interview.
During the home visit, our social worker will be learning about you r family and discussing topics such as criminal history,
CPS history, past and present relationships, family functioning, the birth parent(s) and the child(ren)’s understanding of th e
adoption. If you have concerns about any of these topics, please contact our social worker (520 -724 -9239 ) prior to your
home visit.
After the interview, our social worker will prepare a report for the Court which includes a recommendation as to whether
the adoption appears to be in the best interest of the child(ren).
STEP 3: FINAL ADOPTION HEARING
The final adoption hearing is usually held one to two months after all materials have been processed. The final adoption hear ing is
set by the County Attorney’s office and must be attended by the petitioners and the subject child( ren) . Adoption is a celebration
and you may invite family members and friends to attend the hearing with you. You will receive a letter once your family is ready to
meet with the County Attorney.
Veronica Hookland - Support Staff Priscilla Ordonez - Case Worker
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SUPERIOR COURT OF THE STATE OF ARIZONA
Pima County Juven ile Court
Adoptions & Guardianship Program
2225 EAST AJO WAY
TUCSON, ARIZONA 85713 -6295
520 -724-2920; 520 -724 -9239
FAX 520 -724 -4740
A N ote to Prospective A doptive Parents:
The Juvenile Court Adoptions Program, the Judges and the County Attorney’s office
encourage all families to have an open conversation with their child(ren) about the
upcoming adoption. Honesty, with age appropriate words and information , is extremely
impo rtant. If you are concerned about having this conversation, please contact our social
worker, Priscilla Ordonez , at 520 -724 -9239 for some information and articles to assist
you. Below is a brief list of words and phrases to use to positively discuss adoptio n.
Thank you for your time and attention to this important aspect of the adoption journey.
Positive Language Negative Language
Birthparent
Biological parent
Birth child
My child
Born to unmarried parents
Terminate parental rights
Make/Made an adoption plan
To parent you
Biological or birthfather
Making contact with
Parent
Was adopted
Real parent
Natural parent
Own Child
Adopted child; Own child
Illegitimate
Give up
Give Away
To keep you
Real father
Reunion
Adoptive parent
Is adopted
Veronica Hookland - Support Staff Priscilla Ordonez - Case Worker
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REL ATIVE ADOPTION Rev. 3/2014
Talking to Children about Adoption
What's the best way to handle my child's questions about her adoption?
Many parents want to know when is the best time to tell a child she is adopted. The answer is that it is never too early to t alk to
your child about adoption. Be fore age 3, include age -appropriate children's books on adoption as part of your child's reading
routine. Give your child information little by little, as much as she can understand. It may take years for your child to ful ly
understand what adoption means. These early talks will give you practice in talking about adoption. They will also show your
child that it is OK to bring up the topic.
Here Are Some Tips On How To Talk About Adoption In Your Everyday Life:
Tell the story . Just as any child delights in the story of the day she was born, a child who is adopted will love to hear the details
of how she came into the family. Share with your child the joy you felt at bringing her home that very first day. Talk with h er
about th e many ways children join families —whether by adoption or birth, or in foster care or stepfamilies.
Share the memories . During the adoption process, keep a scrapbook or journal the same way an excited mother does during
pregnancy. Keep track of important d ates and steps in the process. Take pictures of the people and places involved in your
child's earlier life. These details will help make the adoption easier for your child to understand. You may want to place pi ctures
in your child's room to encourage her to ask questions about her adoption. If you have an open adoption, you could frame a
picture of her birth parents. If she was adopted internationally, maybe frame a picture from her place of origin.
Use the words . The word adopted should become a part of your child's vocabulary early on. Find other words that everyone in
your family is comfortable with. The terms birth mother and birth father are very common. Biological parents is also used
frequently. Let your child know that the words mother and father have more than one meaning. A mother is someone who gives
birth to a child, but a mother is also someone who loves, nurtures, and guides a child to adulthood. Being a father also can have
different meanings.
Adoptive parents often tell their child she is special because she was "chosen" or that she was "given up out of love." Though
the parents mean well, these statements may be very confusing to a child. Some children may feel that being chosen means
they must always be the best at everything. This can le ad to problems when they start to realize this is not possible. Telling your
child she was given up out of love may raise questions about what love is and whether others will give her up too. Some famil ies
use the term "making an adoption plan" or “placed for adoption” instead of "giving up" their child.
Don't wait . The longer you wait to talk about adoption with your child, the harder it will be. Any level of openness you can build
when your child is young will help encourage her to ask more questions abou t her adoption as she gets older.
Ask for help . If talking with your child about adoption is difficult, talk with your pediatrician. He or she can be a valuable source
of support, understanding, and resources.
Questions Your Child Might Ask
Even if you tal k about adoption early and openly, at some point your child may begin to ask questions such as
"Did I grow in your body, Mommy?"
"W hy did my birth mother give me away?"
"Did she and my birth father love each other?"
"W hat was my name before I was adopt ed?"
"W hat nationality am I?"
"Do I have brothers or sisters?"
Be honest and open . If your child feels that you are not telling the whole story, he may look for answers somewhere else, like
from a relative or friend who may not know or may not share acc urate information. Show your child that you are willing to talk
about the adoption. Tell him it's OK to bring it up with you.
Avoid responding with your own worries like "Why do you want to know?" or "Are you unhappy with our family?" Your child's
curiosit y is healthy and natural. It should not be discouraged or seen as a threat to you. Also be sure to only answer the
questions the child has asked, not what you think he should know.
Don't force the issue on your child . Some children are curious from the ver y beginning. Others may be afraid to bring it up.
The best you can do is let your child know it is OK to talk about it. When your child is ready to know more, he will ask.
Questions Others May Ask
Other people might ask questions that your child will not be able to answer, from innocent questions like:
"W here did you get those big, blue eyes?"
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REL ATIVE ADOPTION Rev. 3/2014
"Do you look more like your mom or your dad?"
To important medical questions such as:
"Do you have a family history of heart disease, cancer, or diabetes?"
"W hat is your ethnic background?"
Questions from strangers can be tricky. You do not have to tell everyone your child is adopted. However, if a question comes up
about differences in appearance or ethnicity, offer a simple but honest explanation. When you are proud of your child's identity,
she too will learn to appreciate her own value. Be aware that your attitude about adoption will show in your answers. How you
respond can set an example as to how your child may choose to answer these questions in the future . Also, let your child know
that she does not have to give specific answers to strangers if she does not feel comfortable. It is her choice to share what ever
information about her adoption that she chooses. It is fine for children to learn that information about their adoption is theirs to
share over time.
The Gift of Each Other
Helping your child accept the fact that she is unique, yet just like everyone else, may not sound easy, but it is important t o try.
Talking openly and truthfully with your child ab out her history of adoption, her birth parents, and her feelings is the key. Adoption
gives both you and your child a tremendous gift –the gift of each other. With love, honesty, and patience, you and your child will
form a relationship that is as deep and meaningful as any bond between a parent and child.
Source Adoption: Guidelines for Parents (Copyright © 2007 American Academy of Pediatrics, updated 5/07)
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REL ATIVE ADOPTION Rev. 3/2014
DOCUMENT CHECKLIST
Please use this checklist to make sure you have completed all forms and that all documents are available
PRIOR to scheduling your fingerprint appointment.
When applying for a step parent adoption, both the birthparent AND the step parent are considered
applicants. BOTH must complete all information and provide all requested documents.
__________________________________________________________________________________________
Documents contained in the packet:
___ Application for Adoption
___ Fee Sheet Signature Page
___ List of References (with complete addresses, phone numbers and email addresses)
___ Release of Information
___ Adoption Questionnaire
_____________________________________________________________________________________________________ _________________________________ Documents to collect:
___ Marriage license
___ Divorce decrees or death certificates for all previous spouses of each applicant
___ Birth Certificate for each child being adopted (Please bring the original)
*If child does not have a United States birth certificate then also include a copy of his/her valid, non -expired legal residency documents.
This program is not accredited to perform adoptions of children who are not permanent legal residents of the United States (i nter -
country adoptions).*
___ Legally -free documentation from each absent parent ( please check appropriate box ):
Consent for Adoption
Order of Severance/Termination of Parental Rights
Putative Father Registry Certificate of No File Found
Death Certificate
___ Picture Identification for each adult applicant
___ Proof of Pima County Residency (current rent receipt, mortgage or utility bill)
___ Legal Residency documentation if either of the applicants is born outside of the United States
___ Proof of family income (Federal tax forms or W -2’s for most recent tax year)
Pay earning statements are not sufficient proof of income and cannot be accepted
___ Fee payment in the amount indicated on the Fee Sheet on Schedule. Form of payment may be:
money order, personal check or cashier’s check made payable to: Clerk of The Superior Court.
___ Other__________________________________________________________ _________________________
___ Other___________________________________________________________________________________
___ Other___________________________________________________________________________________
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ADOPTION FEE SHEET – Schedule I
Use this schedule for STEP PARENTS, GRANDPARENTS, GREAT -GRANDPARENTS, SIBLINGS, or immediate
AUNTS and UNCLES to adopt children related by blood, marriage or previous adoption.
As required by Pima County Juvenile Court Administrative Order 07 -01, ARS 8 -133 (b) “T he Pima
County Juvenile Court assesses all applicants for adoption for a one -time fee to cover the cost of the
administrative work associated with an adoption.”
The Adoption Fee is to cover the cost to process the application for adoption and does not gua rantee
that adoption will be recommended. The fee is non -refundable , even if the adoption is delayed or
denied, but will be deducted from the Social Study fee if required.
The Adoption fee is $25.00.
If a social study is required to complete your adopti on an additional fee will be required. The fee for
social study includes services for one subject child and his/her two birthparents. A $30 fee will be
charged for each additional subject child and each of his/her birthparents if the birthparents are
diff erent than those of the first subject child.
The fee is based on the combined gross annual income (before deductions) of the prospective adoptive
parent(s) and their spouse (in a step -parent adoption the income if the birth parent who is married to
the ste p-parent is included) for the previous tax year.
The Social Study Fee is $600.00.
Some families may be eligible for a reduced fee based on the sliding fee scale listed below.
You may qualify for further fee reduction or fee waiver if your family has a financial hardship . To submit a request for a reduction or waiver, you will need to submit a detailed letter explaining your family’s circumstances and a copy of the previous year’s tax return.
GROSS ANNUAL INCOME AND FEE SCALE
$55,000 -and over...……………$600.00
$50,000 -54,999………………. $500.00
$45,000 -49,999………………. $400.00
$40,000 -44,999………………. $300.00
$35,000 -39,999………………. $200.00
$25,000 -34,999………………. $100.00
$0 -24,999 ……………………. $0.0
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REL ATIVE ADOPTION Rev. 3/2014
Application for Adoption Social Study, Certification Home Study or Re -Certification
(Please print or type all information)
1st Applicant : _________________________ ________________________ _____________________
Last First Middle
______________________ __________ _________________________
Date of Birth Age Social Security Number
2nd Applicant : _________________________ ________________________ _____________________
Last First Middle
______________________ __________ _________________________
Date of Birth Age Social Security Number
Relationship to child(ren) being adopted: _____________________________________________________________
Have you ever applied to be or are you currently a licensed foster pare nt in Arizona? _____ No _____ Yes
Have you previously adopted a child OR applied for adoption certification within the last three years in Arizona?
_____ No _____Yes – If yes, please provide the date and file number: ___________________________________________
Applicant(s) Address and Phone Numbers
______________________________________________________________________________________________________
Street Address City State Zip
___________________________ ___________________________ ___________________________
Home Phone Cell or Work Phone Cell or Work Phone
ADDITIONAL INDIVIDUALS 18 YEARS OF AGE OR OLDER, LIVING IN THE HOME:
_______________________________________ _________________________ ____________________________________
Full Name Date of Birth Social Security Number
____________________________ ___________ _________________________ ____________________________________
Full Name Date of Birth Social Security Number
_______________________________________ _________________________ ____________________________________
Full Name Date of Birth Social Security Number
I / We verify that the above statement is true and correct to the best of my/our knowledge.
___________________________________ ___________________________________________ _____________________
Signature Printed Name Date
___________________________________ ___________________________________________ _____________________
Signature Printed Name Date
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REL ATIVE ADOPTION Rev. 3/2014
ADOPTION SOCIAL STUDY FEE
SIGNATURE PAGE
TO BE COMPLETE D WITH ADOPTIONS PROGRAM STAFF AT FINGERPRINTING APPOINTMENT.
Adoption Fee of $25 paid on _______________________ __________ _______ __ _
Date Applicant Initial Staff Initial
I / We have read the applicable fee schedule and have attached the following items:
1. Money Order or Personal Check in the amount of $ 25.00
Made payable to: Clerk of The Superior Court.
2. Copy of the Applicants’ most recent Federal Tax Return.
If married and filing separately, you must include tax forms for each spouse.
If ordered by the court, your social study fee will be:
** Social Study fee as determined by FEE SCHEDULE I $ ________________
The social study fee includes serv ices for one child two birthparents
Additional Child(ren): $30.00 X __________ $ ________________
Number of children IN ADDITION to the first child to be adopted
Additional birthparent(s): $30.00 X __________ $ ________________
To be charged if ad ditional children have different birth parents
Minus Adoption Fee - $25
TOTAL SOCIAL STUDY FEE DUE: $ ________________
**This fee will be collected only if a social study is ordered***
I/We understand that the Social Study Fee is to cover the cost of the process of application for adoption and does not
guarantee that adoption will be recommended. I/We understand that if a social study is required to complete our
adoption an additional fee will be required . I/We understand that the fee is non -refundable, even if the adoption is
delayed or denied.
______________ _____________________ ____________________________________ ______________
Signature Printed Name Date
_______ ____________________________ ____________________________________ ______________
Signature Printed Name Date
___________________________________ ______________
Signature of Adoptions Program Staff Date
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REL ATIVE ADOPTION Rev. 3/2014
List of References
First Reference must be a relative of one of the applicants:
1. ______________________________ ______________________ ___________________________
First Name Middle Name Last Name
Relationship: ___ _____ __________ _______ Years Known: _________ Occupation: ______ ___ _______ ____________ ______
Mailing address : ___________________________________________________________________________
Street (include apt or space #) City State Zip Code
Phone: _______________________ Phone: _______________________
__________________________________________ ________________________________________________
Additional references cannot be related to either of the applicants and must have known both applicants for two or more years .
2. ______________________________ ______________________ ___________________________
First Name Middle Name Last Name
Relationship: ___ _____ __________ _______ Years Known: _________ Occupation: ______ ___ _______ ____________ ______
Mailing address : __________________________________________ _________________________________
Street (include apt or space #) City State Zip Code
Phone: _______________________ Phone: _______________________
__________________________________________________________________________________________
3. ______________________________ ______________________ ___________________________
First Name Middle Name Last Name
Relationship: ___ ___ ____________ _______ Years Known: _________ Occupation: ______ ___ _______ ____________ ______
Mailing address : ___________________________________________________________________________
Street (include apt or space #) City State Zip Code
Phone: _______________________ Phone: _______________________
_________________________________________________________________________________________
4. ______________________________ ______________________ ___________________________
First Name Middle Name Last Name
Relationship: ___ _____ __________ _______ Years Known: _________ Occupation: ______ ___ _______ ____________ ______
Mailing address : ______________________________________________________________________ _____
Street (include apt or space #) City State Zip Code
Phone: _______________________ Phone: _______________________
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REL ATIVE ADOPTION Rev. 3/2014
SUPERIOR COURT OF THE STATE OF ARIZONA
Pima County Juvenile Court
Adoptions & Guardianship Program
2225 EAST AJO WAY
TUCSON, ARIZONA 85713 -6295
520 -724 -2920; 520 -724 -9239
FAX 520 -724-4740 _________________________________________________________________________________________________________
Release of Information
I / We ________________________ and ______________________
do hereby permit the employees of the Pima County Juvenile Court Center
Adoptions/Guardianship Program to obtain any and all documents, information
and inquiries necessary to complete the adoption, certification or guardianship
review process. (A.R.S 2.8 -112 )
This consent is valid for six months or the completion of court action, unless
revoked in writing by the undersigned.
Signed,
______________________________ __________________
Name Date
______________________________ __________________
Name Date
Veronica Hookland
Support Staff
Priscilla Ordonez
Case Worker
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REL ATIVE ADOPTION Rev. 3/2014
ADOPTION QUESTIONNAIRE
Please complete the following as completely and accurately as possible , as it will be included in the legal file .
__________________________________________________________________________________________
Male Applicant
Name: _______________________________________________ __________ __________ Primary Language: _____ _____ _______
First Middle Last Interpreter needed? _ __ NO ___YES
What is your relationship to the child being adopted : Birth F ather Step Fath er Grandfather Uncle Other: _______ _________
Date of birth: _______________________ Place of bi rth: _____________________________ Ethnicity: _____________________
Phone: _________________________ Phone: ________________________ Social Security Number: _______________________
Please list any physical health and/or mental health diagnoses and your curren t treatment: _________________ ________________
________________________________________________________________________________________________ _______ ________________________________ _____________________________________________________________________________________________________________________________ __________
Do you have any history of substanc e abuse, including alcohol? If yes, please describe, using additional pages if necessary: ________
_____________________________________________________________________________________________________________________________ __________ ______________________________________________________________ _________________________________________________________________________
Have you ever participated in behavioral health services, including counseling or psychia tric care? Please describe: ___ ___________
________________________________________________ _______________________________________________________________________________________ _____________________________________________________________________________________________________________________________ __________
Have you ever been arrested or charged with a crime in this or any other state, including traffic violations? _____ NO _____YES If
YES, please give date, place & explanation, using additional pages if necessary: _______________ _____________________________
__________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ __________
Have you ever had allegations against you or been investigated by Child Protective Services in this or any other state?
_____ NO _____YES If YES, please give date, place & explanation, using additional pages if necessary: _______________ ______
_______________________________________________________________________________________________________________________________ ________ _________________________________________________________________________________________________________________________ ______________
_______________________________________________________________________________________________________ ___ __
Female Applicant
Name: ___________________________________________________________________ Primary Language: _________________
First Middle Last Maiden Interpreter needed? ___ NO ___YES
What is your relationship to the child being adopted: Birth Mo ther Step Mo ther Grandmother Aunt Other: _______ ___ ____
Date of birth: _______________________ Place of birth: _____________________________ Ethnicity: _____________________
Phone: _________________________ Phone: ________________________ Social Security Number: _______________________
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REL ATIVE ADOPTION Rev. 3/2014
(Female applicant continued)
Please list any physical health and/or mental health diagnoses and your current treatment: ___________________ ______________
____________________________________________________________ ___________________________ _______________________________ _________________ _______________________________________________________________________________________ ___________________________ _____________________
Do you have any history of substance abuse, includin g alcohol? If YES, please describe, using additi onal pages if necessary: _______
____________________________________________________________________________________________________________ ___________________________ _____________________________________________________________________________________ _______________________ ___________________________
Have you ever participated in behavioral health services, including counseling or psychiatric c are? Please describe: _________ _____
_________________________________________________________ ______________ _____________ ___________________________________________________ ____________________________________________________________________________________ ___________________________ ________________________
Have you ever been arrested or charged with a crime in this or any other state, including traffic violations? _____ NO _____YES If
YES, please give date, place & explanation, using additional pages if necessary: ___________________________________________
______________________________________________ ______________________________________________________________ ___________________________ ____________________________________________________________________________________________________________ ___________________________
Have you ever had allegations against you or been investigated by Child Protective Services in this or any other state?
_____ NO _____YES If YES, please give date, place & explanation, using additional pages if necessary: __________ ___ _______ __
__________________________________________________ ___________________________ __________________________________________________________ _____________________________________________________________________________ ___________________________ _______________________________
____________________________________________________________________________________________________________
Both Applicants
Date & location of current marriage: _____________________________________________________________ _________________
Home address: _______________________________________________________________________________________________
Street Apt # City State Zip Code
Do you currently have legal guardianship or temporary legal custody of the child(ren) to be adopted? _____ NO _____YES
If YES, Where: ______________________________ Case Number: ____________________ Date issued: _________________
Has either applicant ever applied to adopt any child in the past? _____ NO _____YES If YES, please explain:
_______________________________________ ___________________________ _____________________________________________________________________
Has either applicant ever been involved in any Adoption, Severance or other Juvenile Court matter , in any state ? _____ NO ____YES
If YES, provide case number and explanation: ____ ______ ____________________________________________________________
Has either applicant ever been denied an adoption or certification in any state? _____ NO ____YES If YES , please explain:
__________________________________________________________________________________________________ ___________________________ __________
Please give the name & relationship of whom you have chosen to raise your children in the event of your serious illness or death:
____________________________________________________________________________________________________________ ___________________________
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REL ATIVE ADOPTION Rev. 3/2014
Please de scribe why you are applying for adoption, using additional pages if necessary: _____________ _______ ________
_____________________________________________________________________________________________________________________________ __________ __________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____ ______
Have you talked with your child(ren) about the adoption? ______YES ______NO
____________________________________________________________________________________________________________
Information about the child(ren) you wish to adopt
First: ______________________________ Middle: _________________________ Last: ________________________________
*Child’s full, legal birth name, as it appear s on the birth certificate*
First: _______________________________ Middle: _____________________ ____ Last: ________________________________
*Proposed Name Change*
Date of birth: ______________ ___ _______ Place of birth: _____________________________ Ethnicity: _________ ___________
When did the child begin living with you? _________________________________________________________________________
How did the child come into your custody? ________________________________________________________________________
_________________________________________________________________ ____________________________ ___________________________ _______________
Please list any ph ysical health and mental health diagnoses for the child and current treatment: ____________ ____________ ______
_______________________________________________________ _____________________________________________________ ___________________________
____________________________________________________________________________________________________________
First: ______________________________ Middle: _________________ ________ Last: _______________________ _________
*Child’s full, legal birth name, as it app ears on the birth certificate*
First: _______________________________ Middle: _________________________ Last: ________________________________
*Proposed Name Change*
Date of birth: ________________________ Place of birth: _____________________________ Ethnicity: _____________________
When did the child begin living with you? _______________________________________________________________ __________
How did the child come into your custody? ________________________________________________________________________
_____________________________________________________________________________________ ___________________________ ________________ _______
Please list any physical health and mental health diagnoses for the child and cu rrent treatment: ______________________________
_____________________________ ________________________________________________________________________________________
*Please use additional copies of this page for more children**
____________________________________________________________________________________________________________
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Birth Par ent Information (NON -APPLICANT BIRTH PARENTS ONLY)
Name of Birth M other : ______________________________ ___ ___ Date of birth o r approximate age: ____________ ___________
Last known location: _____________________________________ Last contact with child: ________ _______ _________________
Last contact with applicant(s): _____________________________ _____________________________________________________ _
Please list any physical health, mental health & substance abuse issue s for the birth mother: ______ __________________________
_____________________________ _____________________________________________________________________ ___________________________ __________
Name of Birth F ather : _____ _______________________________ Date of birth or approximate age: ___________ _____________
Last known location: ______ _______________________________ Last contact with child: ________________________________
Last contact with applicant(s): ___________________________ _____________________________________________________ ___
Please list any physical health, mental hea lth & substance abuse issues for the birth father: _____ ____________________________
_____ ___________________________ _______________________________________________________________________________________________________
Dat e of severance or consent by birth parent(s) : ___________________ ________ __________________ _______________________
___ ___________________________ _________________________________________________________________________________________________________
_________________________________ ___________________________________________________________________________
I / We verify that the information reported in this packet is true and correct to the best of my/our knowledge.
_________________________________________________ _____________________________________________________ _______ __________________ Signature Printed Name Date _________________________________________________ _____________________________________________________ ______ __________________ Signature Printed Name Date
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