Birth Parents Application of Services
|
|
- Steven Simon
- 8 years ago
- Views:
Transcription
1 If yes, who? self parent grandparent If yes, who? self parent grandparent With what tribe? With what tribe? Single Single Married Marriage Date(s) & Place: Married Marriage Date(s) & Place: Spouse Name: Birth Parents Application of Services Birth Parents' Information Date of application: Birth mother name (please print) Birth father name (please print) Birth mother's race Birth father's race Native American heritage? Yes / No Registered? Yes / No Native American heritage? Yes / No Registered? Yes / No Spouse Name: Divorced Divorce Date(s): Divorced Divorce Date(s): Separated Separation Date: Separated Separation Date: Current Living Arrangements? Deceased Death Certificate Date: Please provide all applicable documents such as marriage license, divorce/separation decrees, and/or death certificate. Have you ever been diagnosed with sickle cell anemia or sc anemia trait? Yes / No Birth father? Yes / No Please specify Please describe your relationship with the birth father including any concerns you have: If the birth father is unknown, what are the circumstances of the pregnancy? Does he know you are pregnant? Yes / No Does he know you are considering adoption? Has he helped you financially? Yes / No How much? Yes / No Does he agree the child is his? Yes / No Is he willing to consent to adoption? Yes / No Has he supported you any other way? Yes / No If yes, please explain: Commitment to Adoption On a scale of 1 to 10 with 10 being most committed, how sure are you about placing your child for adoption? Why? Who is aware of and supportive of your decision to place your child for adoption? Have you ever placed a child for adoption before? Yes / No If yes, when and where? How did you hear about A Guardian Angel Adoptions? (Mark all that apply) Yellow Pages Internet Facebook Twitter Google Referal (who) Pregnancy Information Due date of baby: Sex of child: Male Female Unknown First day of last period: Do you know where you want to deliver? If yes, city and state? Hospital and doctor? Willing to travel to Utah to deliver baby? Yes / No If yes, when would you plan to arrive in Utah? Have you ever been pregnant before? Have you ever had a miscarriage? Have you started prenatal care? Date of last visit: Results: Have you had an ultrasound or sonogram? When? Where? Results: Current doctor Have you discussed adoption with a doctor? Will you continue to see this doctor? Office phone Location:
2 Birth mother's full name Date of birth Street address Birth Mother Personal Information First Middle Last Maiden (if applicable) Age Place of birth US citizen Yes / No if no, citizen of what country? City State Zip Home phone Cell phone Other phone Social security number Driver's license number (if applicable) State issued Height: Weight: Hair color: Eye color: Physical build (big/small boned, muscular, etc.): Complexion (circle one): fair, medium, olive, dark Unique features (freckles, moles, etc.): Which of the following describes your personality? (circle all that apply) Aggressive Calm Friendly Fun Irresponsible Nervous Critical Emotional Other: Name: Address: Happy Helpful Outgoing Open-minded Emergency Contact Information: Relationship: Phone number: Rebellious Selfish Self-Confident Serious Shy Stubborn Temperamental Unhappy Friend or relative who would be able to contact you in the future: Name: Relationship: Address: Phone number: Presently in school? College/Vocational training? If yes, describe: Current occupation Birth Mother Education and Employment Information Last grade completed? Average grades received? Diploma or GED? Military service? If yes, what branch? Work address and phone number Other Children Information Age & Birth How Any physical/ Living Name Sex birth date weight/length delivered? mental problems? with you? If no, where? Do you have medical insurance? Pregnancy Related Expenses Yes / No Name of company? Work or personal? Do you receive financial assistance from any source? How much money do you need a month to cover expenses? $ Yes / No Source? Describe expenses: Amount per month?
3 Drug History Please fill out the following drug history to the best of your knowledge. In the space "when used" please state if you used the drugs "before conception" or "during pregnancy" or, both if applicable. Name How much How often When used Name How much How often When used Prescription Cocaine Over-the-counter (pain/cold/allergy medicines) Alcohol Amphetamine Barbiturate Cigarettes Heroin LSD Marijuana Meth Other Other Mental Illness History Please indicate if you, the birth father, or anyone in either family has any of the following: Depression Yes / No Bipolar Yes / No Schizophrenia Yes / No Panic Attack Yes / No Who: Who: Who: Who: Please list any physical illnesses or mental illnesses you or the birth father might have: Birth mother: Birth father: Birth father's full name Birth Father Personal Information First Middle Last Unknown Date of birth Street address Age Race US citizen Yes No if no, citizen of what country? City State Zip Phone Height: Weight: Physical build (big/small boned, muscular, etc.): Hair color: Complexion (circle one): fair, medium, olive, dark Eye color: Unique features (freckles, moles, etc.): Which of the following describes the birth father's personality? (circle all that apply) Aggressive Friendly Irresponsible Rebellious Shy Calm Fun Nervous Selfish Stubborn Critical Happy Outgoing Self-Confident Temperamental Emotional Helpful Open-minded Serious Unhappy Other: Birth Father Education and Employment Information Presently in school? Last grade completed? Average grades received? Diploma or GED? College/Vocational training? If yes, describe: Military service? If yes, what branch? Current occupation Work address and phone number Adoptive Family Information Would you like to choose your adoptive family? Yes / No Would you like to talk with your adoptive family? Yes / No Would you like to meet your adoptive family? Yes / No What contact do you want from the family after the baby is born? (circle all that apply) Pictures: Regularly Occasionally Never Letters: Regularly Occasionally Never Other:
4 Values and Characteristics of Adoptive Family Please be aware A Guardian Angel Adoptions, LLC cannot guarantee that your adoptive family will meet all your preferences. We do not discriminate against families based on marital status, sex, or religion. Please discuss any preferences you feel especially strong about before you decide to use our services. (Please circle all that apply) Marriage: Two parent Single Does not matter Other Age: Young Middle-aged Does not matter Other Race: Same as baby Caucasian Does not matter Other Children: None One or two Does not matter Other Education: Important Moderate Does not matter Other Financial: Wealthy Secure Does not matter Other Religion: Christian Non-Christian Does not matter Other Please describe your ideal adoptive family: What is the most important characteristic you want in an adoptive family? Please list any other concerns or questions you may have. I certify to the best of my knowledge that the information provided here is true and correct and I am signing this of my own free will. Signatures Birth mother name Date Birth mother signature Birth father name Date Birth father signature
5 Statements of Understanding Purpose The purpose of this form is for the birth mother to understand all her rights and the rights of A Guardian Angels Adoptions, LLC through the adoption process. Please initial each statement, only after you have thoroughly read each statement. Statements Right to Parent: Birth Father Rights: Application for Services: Fraud Statement: Policies and Procedures: Alcohol and Drug Use: Drug/HIV Testing: Statements Purpose or Explanation As the birth parent of my child, I have the primary right to parent my child if I so choose, even if I am a minor. I will make sure that it is my wish to place my child for adoption before I begin working with A Guardian Angel Adoptions, LLC. I understand that according to the adoption laws of the state of Utah that the birth father may have the option of parenting the child if he is known and paternity has been established. In order to establish paternity in Utah, he must support me emotionally and financially during my pregnancy or he must file with Utah Vital Records on the State Paternity Registry. Paternity laws of the father s state of residence must also be complied with. Furthermore, I understand that if a birth father resides in another state and I am withholding information about my whereabouts, I may be putting my adoption placement in jeopardy. Also, if I am married, my legal husband must consent to an adoption even if he is not the child s biological father. Notice must also be given to any birth father I may identify on the birth certificate. I, at my own discretion, have decided to apply with A Guardian Angel Adoptions, LLC for assistance with my adoption plans. All information I have supplied throughout the application process is true and correct to the best of my knowledge. I understand that misrepresenting my pregnancy or my desire to place for adoption is considered fraud. I also understand that receiving assistance and support from more than one adoption agency at the same time may also be considered fraud. A Guardian Angel Adoptions, LLC may choose to prosecute me if I have committed a fraudulent act. I also understand that adoption agencies may share information about me with other agencies in an effort to prevent fraud. I understand that there are Policies & Procedures of A Guardian Angel Adoptions, LLC that I must follow. If I decide not to follow these policies I understand that A Guardian Angel Adoptions, LLC has the right and responsibility to discontinue their services. Before accepting any services from A Guardian Angel Adoptions, LLC, I agree to follow those Policies and Procedures. I understand the use of alcohol or illegal drugs during my time as a client with A Guardian Angel Adoptions, LLC is prohibited. If I am using drugs or alcohol while I am a client through this agency, they have the option of terminating services and/or referring me to a drug or alcohol treatment facility as well as to the appropriate law enforcement. I understand that A Guardian Angel Adoptions, LLC will request that I participate in drug and HIV testing. These tests are done automatically for all birth parents working with A Guardian Angel Adoptions, LLC. Initial here Jurisdiction: If I chose to travel to Utah, I expressly submit to the jurisdiction of the courts of the state of Utah and agree to be bound by laws of Utah. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT Statements of Understanding 5
6 Choice to Travel: Statement of Liability: Living Expenses: Living Arrangements: Release of Information: Counseling: Permission: Other Services: Privacy Statement: Selection and Information Sharing: I understand that A Guardian Angel Adoptions, LLC neither encourages nor recommends longdistance travel by any means within two weeks of my due date. If I choose to travel to Utah, I take full responsibility for my decision to travel and for any consequences resulting from the trip, be they physical, financial, emotional, or otherwise, for myself and for any of my children traveling with me. I willingly and knowingly choose to leave, the state in which I have been residing, and release A Guardian Angel Adoptions, LLC from responsibility for the choice to travel. I acknowledge that A Guardian Angel Adoptions, LLC is providing services to me in good faith and I do not hold them responsible or liable in any way for any harm or accident that may come to me during my association with them. I understand that A Guardian Angel Adoptions, LLC may assist me with necessary living expenses during my pregnancy including rent, food and utility payments if allowable in the state of services. A Guardian Angel Adoptions, LLC will also assist me in accessing any local resources that may be available to me during my pregnancy or following the delivery of my child. I understand the agency is limited by law regarding the assistance offered. I understand A Guardian Angel Adoptions, LLC is unable to pay for past bills or deposits. I understand it is my choice to choose one person to support me through my pregnancy and the adoption process, but at any time should my support person be found using, or in possession of drugs or if they become physically or mentally abusive to me, my children, or any member of A Guardian Angel Adoptions, LLC, he/she will be IMMEDIATELY escorted to the nearest bus station to return home. There are no exceptions to this rule. I understand that in signing the "Release of Information" form that I am authorizing any and all psychological, psychiatric and health information or birth certificate records pertaining to me or any child of mine to be released to A Guardian Angel Adoptions, LLC. I understand that A Guardian Angel Adoptions, LLC will provide me with counseling and support me to help me in making decisions concerning my pregnancy. A licensed social worker or a professional counselor will be assigned as my counselor to assist me throughout the adoption process. I give permission for my caseworker and social worker to discuss my case with other staff members of the agency, health care workers, other adoption agencies and law enforcement officers as needed. I understand that services are rendered on a case-by-case basis and that services provided to another birth mother may not be the same as those provided to me. I understand that A Guardian Angel Adoptions, LLC will not disclose my last name, address, phone number or any other identifying information to the adoptive family without my permission; however, they cannot guarantee privacy in any adoption. If I place my child with A Guardian Angel Adoptions, LLC I may be involved in the selection of an adoptive family. I understand that non-identifying information about the other birth parent, the pregnancy, and myself will be shared with any family I may be considering as potential parents for my child. I have signed or will sign a release of information, allowing information specifically for this purpose. Adoptive Placement: A Guardian Angel Adoptions, LLC will assist me in selecting the adoptive parents who match my request, though they cannot guarantee all my preferences will be met. All adoptive parents have been thoroughly screened by A Guardian Angel Adoptions, LLC and found appropriate for the placement of my child. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT Statements of Understanding 6
7 Adoptive Placement (cont): I understand that based on Utah Law, A Guardian Angel Adoptions, LLC may not place a child with anyone who is cohabiting in a relationship that is not a legally valid and binding marriage under the laws of Utah. Cohabiting is intended to mean residing with another person and being involved in a sexual relationship with that person. I understand I have the option to choose the adoptive parents. If I forgo this choice, A Guardian Angel Adoptions, LLC will choose the adoptive parents they feel most appropriate to adopt my child. Religion Statement: I understand and agree that A Guardian Angel Adoptions, LLC is placing my child with a family that may or may not practice religion as I do and that the adoptive parents will raise my child in the faith of their choice. A Guardian Angel Adoptions, LLC does not discriminate against adoptive families because of religious affiliation. Elective Post Operative Surgery: I understand that if I choose to have an elective post operative surgery, I will be responsible for all associated charges incurred. Elective post operative surgery is not considered an adoption related expense, and therefore, CANNOT be reimbursed. Services Provided: I understand that staff members of A Guardian Angel Adoptions, LLC who are providing me services may also be providing services to the adoptive family. I also understand that such an arrangement might create a conflict of interest between my concerns and the concerns of the adoptive family. Irrevocable Relinquishment: Openness Agreement: Post-Placement Arrangements: If I decide on an adoption plan for my child, I will sign the relinquishment papers. I understand that I must wait at least 24 hours following the delivery of my child to sign the relinquishment papers. I realize that when I sign the relinquishment and consent paperwork, all my rights and responsibilities to this child will end and that my consent to adoption will be final, irrevocable and legally binding. I understand that A Guardian Angel Adoptions, LLC will assist in working with the adoptive family in regards to the openness agreement by setting up a post-placement plan that meets my specific needs. A Guardian Angel Adoptions, LLC will facilitate the exchange of pictures, letters and phones calls for the birth mothers and adoptive families. I understand that in Utah, openness agreements are not legally binding. I understand A Guardian Angel Adoptions, LLC will provide housing for up to ten days after I place my child for adoption. I will also be given a reasonable amount of financial assistance to help me for up to six weeks following my placement. Additionally, I understand that A Guardian Angel Adoptions, LLC will provide me with transportation back to my home or place of choice. Other post-placement services include facilitation of openness agreement and up to three post-placement counseling visits and/or appropriate counseling and community referrals. Statement of Promises: There have been no promises made to me that would influence my decision to place my baby for adoption. I have not been offered gifts or promises for placing my child for adoption. I understand that gifts or allowances beyond the guidelines set by A Guardian Angel Adoptions, LLC cannot be accepted. Utah Mutual Consent Registry: I understand the Utah Mutual Consent Registry makes it possible for the birth parents and adoptee to be reunited when the adoptee is 18 years of age. I understand that contact will be possible through this resource only if both adoptee and birth parent register. I understand it is my responsibility to initate my desire to be listed with the registry, which is administered by Utah Vital Records. Yes / No (please circle one) Legal Advice: I understand that I have the legal right to consult with an attorney of my own choice and to seek independent legal counsel prior to making the decision to place my child for adoption. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT Statements of Understanding 7
8 Birth Father I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue services Information: if for any reason the initial birth father information I provide, is not consistent with fact. Information I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue Provided: services if for any reason the information provided, is not consistent with fact or actions. Information on I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue Marriage: services if the information provided about any marriages I am in, or have been in are not consistent with the facts. Medical Expenses: I understand that if I decide not to place my child for adoption, I will be responsible for all medical expenses incurred for me and my child. Other Expenses: If for any reason, I choose to parent my baby, I will be responsible for all expenses related to caring for myself, my baby and any other individual that accompanied me to Utah. This includes, but is not limited to, housing and living expenses, baby necessities, and previous, current and future medical care. I agree to find housing/hotel until I leave Utah. Transportation to the city I came from will only be provided by Greyhound Bus service. after I have been medically cleared to travel. No exception to this policy is premitted. Signatures I, am not under the influence of any drugs, alcohol or medication that may influence my reasoning or judgment and am signing this document of my own free will and choice. Birth mother's name (please print) Birth mother's signature Date: Birth father's name (please print) Birth father's signature Date: A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT Statements of Understanding 8
9 Birth Mother Release of Information Authorization For Release of Information TO: ANY PHYSICIAN, MEDICAL FACILITY, PSYCHIATRIST, PSYCHOLOGIST, ADOPTION AGENCY, FEDERAL, STATE, COUNTY OR CITY AGENCY, ATTORNEY OR LAY PERSON. You are hereby authorized to release to the following agency: A Guardian Angel Adoptions, LLC P.O. Box South Jordan, Utah Phone: (801) Fax: (801) Any and all psychological, psychiatric, health information or birth certificate record pertaining to me or any child of mine which is now, or in the future may be, in your possession and are further authorized to verbally discuss any interaction you have had or may have with me. It is hereby expressly authorized to copy or receive copies of any records or documents pertaining to me or the information specified above. This information may be used in connection with any proceeding concerning the adoption, guardianship, custody and control of my child. You are also authorized to release information to the individual or couple that adopts my child, as identified by the Placement Agreement between A Guardian Angel Adoptions, LLC and the adoptive party. MEDICAID If requested, I authorize Medicaid to release information about me or my children to A Guardian Angel Adoptions, LLC. I authorize Medicaid to provide them my Medicaid number and any other information about my case. I understand that if I apply for Medicaid in Utah, my benefits in another state will be cancelled. CHILD'S GENDER I authorize the OB/GYN, RN or ultrasound technician to tell A Guardian Angel Adoptions, LLC the gender of my unborn child if requested, even if I choose not to know myself. I also authorize any other adoption agency, counselor, attorney or other professional who is contracted by A Guardian Angel Adoptions, LLC to release information about me, my child(ren), or this adoption to A Guardian Angel Adoptions, LLC. In addition, I authorize A Guardian Angel Adoptions, LLC to release information about me to other adoption agencies if I have contacted them for assistance. This Authorization shall remain valid for two years from this date. SIGNATURE Birth mother's name (please print) Birth mother's signature Date
A Guide to Adoption Law for North Carolina Birth Mothers
A Guide to Adoption Law for North Carolina Birth Mothers 1. Who may place a child for adoption? Who accepts children for adoption? A parent with legal and physical custody of a child may place the child
More informationNew Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
More informationTransitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
More informationCherokee Nation Child Support Services Post Office Box 557 Tahlequah, OK 74465 918-453-5444
Cherokee Nation Child Support Services Post Office Box 557 Tahlequah, OK 74465 918-453-5444 It s more than money It s about healthy, happy children with a positive future The following pages include an
More informationADOPTION. The Adoption Law All adoptions filed in the state of Missouri are governed by the same 1123
ADOPTION What is Adoption? Adoption is a legal process that establishes a parent/child relationship between two people who are not otherwise related by blood. There are three sets of participants in an
More informationFrequently Asked Questions about Adoption in Kentucky
Frequently Asked Questions about Adoption in Kentucky BIRTH MOTHER RELATED 1. When can the mother of the baby start the adoption process? A. The birth mother can start the adoption process at any time
More informationYou may petition for adoption in the Probate Division of the Vermont Superior Court if:
This chapter includes information about: Who Can Adopt Who Can Be Adopted Procedure for Adoption Rights of People Who Have Been Adopted Adoption of Stepchildren and Others Guardianship of a Minor Emancipation
More informationChild and Home Study Associates
Child and Home Study Associates 1029 North Providence Road 242 N. James St., Suite 202 Media, Pennsylvania 19063 Wilmington, Delaware 19804 (610) 565-1544 FAX (610) 565-1567 (302) 475-5433 APPLICATION
More informationOriginal Petition for Divorce
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA. Cause Number: (The Clerk s office will fill in the Cause Number and Court Number when you file this form.) IN THE MATTER OF THE MARRIAGE OF Petitioner: Print
More informationTEEN CHALLENGE CENTER--PENSACOLA, FLORIDA STUDENT APPLICATION FOR PROGRAM ENTRY. Personal Data and Information. In Case of Emergency Please Contact
TEEN CHALLENGE CENTER--PENSACOLA, FLORIDA STUDENT APPLICATION FOR PROGRAM ENTRY Personal Data and Information TODAY'S DATE BIRTH DATE SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MIDDLE NAME STREET ADDRESS
More informationLifeway Information Form
Lifeway Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please circle home cell
More informationDate of Birth Age Now Date of Birth Age Now
Name Name Address Address Date of Birth Age Now Date of Birth Age Now Is a pregnancy involved: Highest year in school: In school now? If not, date quit: Employment, if any, now: Wages: Savings, if any:
More informationFREQUENTLY ASKED QUESTIONS ABOUT ADOPTION IN FLORIDA
FREQUENTLY ASKED QUESTIONS ABOUT ADOPTION IN FLORIDA BIRTH MOTHER RELATED 1. When can the mother of the baby start the adoption process? A. As soon as she has a confirmed pregnancy, the adoption process
More information8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
More informationMosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION
NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together
More informationWarner Family Counseling
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
More informationDeclaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
More informationFrequently Asked Questions about Adoption in Florida
Frequently Asked Questions about Adoption in Florida BIRTH MOTHER RELATED 1. When can the mother of the baby start the adoption process? A. As soon as she has a confirmed pregnancy the adoption process
More informationSi Ud. no entiende esto, llame a su oficina local del Michigan Department of Health and Human Services.
Si Ud. no entiende esto, llame a su oficina local del Michigan Department of Health and Human Services. From One Parent to Another Raising a child today is not an easy task, even under the best of circumstances.
More informationDeclaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
More informationYou will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items.
Getting started: Health care for children CHIP and Children s Medicaid These programs offer health-care benefits for newborns and children age 18 and younger who live in Texas. With these programs, your
More informationPATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone
PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced
More informationApplication Form. Executive MBA
Department of Business Administration The International School Application Form Executive MBA Instructions All of the following materials must be submitted before your application will be processed: Application
More informationFrequently Asked Questions about Adoption in Tennessee
Frequently Asked Questions about Adoption in Tennessee BIRTH MOTHER RELATED 1. When can the mother of the baby start the adoption process? A. Legal proceedings cannot begin until at least four (4) days
More informationSanta Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
More informationWelcome to Heart to Heart Adoptions
Welcome to Heart to Heart Adoptions AF 1 Welcome to Heart to Heart Adoptions! We are a non-profit 501(c)3 organization committed to building families and a brighter future for birthmothers and children.
More informationADOPTING A CHILD IN MICHIGAN. STATE OF MICHIGAN Department of Human Services
ADOPTING A CHILD IN MICHIGAN STATE OF MICHIGAN Department of Human Services Michigan Department of Human Services Adoption Services Table of Contents A. Introduction... 1 B. Definitions... 1 C. Common
More informationDeclaration of Practices and Procedures
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
More informationOrthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
More informationIntake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
More informationEllyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com
Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation
More informationRecovery Services of Northwest Ohio, Inc.
Recovery Services of rthwest Ohio, Inc. 200 Van Gundy Drive Phone: 419-636-0410 Bryan Ohio 43506 Fax: 419-636-6510 Driver Intervention Program Intake/Screening Interview Name Address Street Social Security.
More informationIn addition to the forms that you have downloaded or had mailed to you, the following forms are needed at or prior to the first home visit:
Necessary Documents for a Home Study Forever Families Home Study Agency, Inc. P.O. Box 1195 Goldenrod, Florida 32733-1195 (407) 977-8639 Foreverfamilies@Bellsouth.net WWW.Foreverfamilieshomestudies.com
More informationTHE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT OF MICHIGAN FAMILY DIVISION JUVENILE
THE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT OF MICHIGAN FAMILY DIVISION JUVENILE Filing Instructions for Guardian Adoptions The mission of the Adoptions Unit is to help ensure permanently joined bonded
More informationYurok Child Support Services 427 F Street, Ste. 236 P.O. Box 45 Eureka, CA 95502 Phone: (707) 269-0695 Fax: (707) 269-0645
Yurok Child Support Services 427 F Street, Ste. 236 P.O. Box 45 Eureka, CA 95502 Phone: (707) 269-0695 Fax: (707) 269-0645 APPLICATION FOR CHILD SUPPORT SERVICES OFFICE USE ONLY: Date Requested: Date received:
More informationROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc.
ROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc. I know you have several pages of paperwork to complete, so I will only take a few moments of your time now to share some important details
More informationADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
More informationNEW PATIENT INFORMATION CONSENT AND AGREEMENT
NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians
More informationJames A. Purvis, Ph.D. Psychotherapy Services Agreement
James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
More informationWake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
More informationWHO MAY ADOPT A CHILD?
Adoption in Florida INTRODUCTION Lawyers and judges receive many inquiries from persons who wish to adopt a child. This pamphlet has been prepared to help you understand adoption laws and procedures and
More informationBiblical Counseling General Intake Form Personal History and Problem Evaluation
Biblical Counseling General Intake Form Personal History and Problem Evaluation Identification Data Name: Phone: Date: Address: Occupation: Business Phone: Gender: Date Of Birth: Age: Education: Last Grade
More informationSouth Carolina Department of Social Services CUSTODIAL PARENT S APPLICATION FOR CHILD SUPPORT SERVICES. Child Support Services
South Carolina Department of Social Services CUSTODIAL PARENT S APPLICATION FOR CHILD SUPPORT SERVICES The disclosure of your Social Security Number is mandatory, in accordance with section 466(a)(13)
More informationOrder in Suit Affecting the Parent-Child Relationship (Nonparent Custody Order)
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA Cause Number: (Write the cause number and other case information exactly as it appears on the Petition.) In the Interest of the following Minor Child(ren):
More information24. How does your disability keep you from working, or cause problems in your ability to maintain work? phone: phone: phone: date(s) date(s) date(s)
USOR-4 (Rev. 8/04) Utah State Office of Rehabilitation VOCATIONAL REHABILITATION APPLICATION PART I: Tell us about yourself. 1. Social Security Number (Office use only) Case #: 2. Legal Name (Last) (First)
More informationGrandparent s Power of Attorney Information and Forms
NOTICE AND DISCLAIMER Grandparent s Power of Attorney Information and Forms The forms in this packet have been provided to you as a public service by the Butler County Juvenile Court. Although you may
More informationAssociates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909
Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
More informationNORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM. Atty Present?: 9 YES 9 NO Interpreter: 9 YES 9 NO
PROB 1A (ND/CA 11/10) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM THIS SECTION TO BE COMPLETED BY U.S. PROBATION OFFICE Date of Interview:
More informationSUPERIOR COURT OF CALIFORNIA COUNTY OF SUTTER
SUPERIOR COURT OF CALIFORNIA COUNTY OF SUTTER M. B. Todd Court Executive Officer 463 Second Street, Yuba City, CA 95991 Civil Division CHILD CUSTODY INVESTIGATION QUESTIONNAIRE This questionnaire will
More informationAre the Children Covered? Yes No. Gross Income Per Payday. Yes No. If yes,
DEPARTMENT OF CHILDREN AND FAMILIES Division of Family and Economic Security Wisconsin Statutes: 49.22 Bureau of Child Support Federal Regulations: 45 CFR 302.33 Guardian s Application for Child Support
More informationPATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
More informationATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT
STATE OF GEORGIA ATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT I,, with a Social Security Number of the undersigned, do hereby retain the Ramos Law Firm, LLC, located
More informationSPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples
More informationFamily Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
More informationUTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION
UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION OFFICE USE ONLY REASON FOR ENROLLMENT (mark all that apply) Policy / Group No. New Group Newborn Loss of Coverage Open Enrollment Court Order Marriage Effective
More informationCOMMONLY ASKED ADOPTION QUESTIONS IN FLORIDA
COMMONLY ASKED ADOPTION QUESTIONS IN FLORIDA How long will it take to get a baby? There is a wide variety of waiting periods dependent upon a host of controllable and non-controllable factors. Generally,
More informationFrequently Asked Questions about Adoption in Georgia
Frequently Asked Questions about Adoption in Georgia BIRTH MOTHER RELATED 1. When can the mother of the baby start the adoption process? A. The mother of the baby can start the adoption process at any
More informationDavid Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457
David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 DISCLOSURE INFORMATION & CONTRACT FOR PSCYHOLOGICAL SERVICES DATE: CLIENT NAME: BIRTHDATE: ADDRESS:
More informationPersonal Contact and Insurance Information
Kenneth A. Holt, M.D. 3320 Executive Drive Tele: 919-877-1100 Building E, Suite 222 Fax: 919-877-8118 Raleigh, NC 27609 Personal Contact and Insurance Information Please fill out this form as completely
More informationHow to use the Utah Will to Live Form SUGGESTIONS AND REQUIREMENTS:
How to use the Utah Will to Live Form SUGGESTIONS AND REQUIREMENTS: 1. The document allows you to designate (name) a health care agent or attorney in fact someone who will make health care decisions for
More informationBIRTH CERTIFICATE APPLICATION
H BIRTH CERTIFICATE APPLICATION PLEASE READ THIS PAGE BEFORE YOU BEGIN TO COMPLETE THIS APPLICATION Only the mother or father should complete this application. We understand there may be certain circumstances
More informationLAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
More informationThank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you!
Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! To simplify the registration process during your first visit we ask that you take a moment
More informationADOPTION & FAMILY INFORMATION SERVICE. Level 1 45 Wakefield Street Adelaide 5000 South Australia. GPO Box 292 Adelaide 5001 South Australia
Level 1 45 Wakefield Street Adelaide 5000 South Australia GPO Box 292 Adelaide 5001 South Australia Phone: +61 8 8207 0060 Fax: +61 8 8207 0066 Email: adoptions@dfc.sa.gov.au Web: www.adoptions.sa.gov.au
More informationAll Foster / Adoptive Parent Applicants must complete the following prior to Becoming a Licensed Homebound Parent
All Foster / Adoptive Parent Applicants must complete the following prior to Becoming a Licensed Homebound Parent 1. Please completely fill out your foster parent applications, if you have any questions
More informationPatient Information Form Trinity Wellness Center. Insurance Information
Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student
More informationwww.adoptionpriorities.com
Adoption Priorities, Inc. is a 501 3 charitable foster care and adoption agency. We are a Christian, non-profit agency licensed by the State of Texas. The statistics are overwhelming: literally hundreds
More informationAdoption in Washington State
Adoption in Washington State A Lifelong Developmental Journey DSHS 22-1096(X) (Rev. 1/05) Adoption A Lifelong Developmental Journey Adoption is the permanent, legal transfer of all parental rights from
More informationOK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
More informationChild s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:
Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent
More informationTo new Moms and Dads...... help your baby get a step ahead in life!
To new Moms and Dads...... help your baby get a step ahead in life! A Special Message to new MOMS: Congratulations on the birth of your new baby. Be a proud parent and help your baby get a step ahead in
More informationComplete all pages of the application, especially the signature page.
Dear Applicant: Thank you for your interest in filing for Crime Victims Compensation benefits. Our goal is to assist victims of crime in accessing financial assistance to help them recover from the traumatic
More informationCATHOLIC CHARITIES OF BALTIMORE 2601 N. Howard Street Suite 200 Baltimore, Maryland 21218 (410) 659-4050
CATHOLIC CHARITIES OF BALTIMORE 2601 N. Howard Street Suite 200 Baltimore, Maryland 21218 (410) 659-4050 INTERNATIONAL CHILDREN'S SERVICES RELATIVE ADOPTION--PRELIMINARY APPLICATION FORM Please enclose
More informationComprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms,
Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, PATIENT INFORMATION Last Name/ First Name/ M.I. Social Security Number: Date of Birth (MM/DD/YY):
More informationHow To Protect Your Health Care Information From Disclosure
Thank you for choosing North Valley Christian Counseling. We look forward to working with you. Please take a few minutes to fill out the following forms. We will also take a few moments at the beginning
More informationPersonal History Statement Application for Law Enforcement Explorer
Name: Date Applied: Personal History Statement Application for Law Enforcement Explorer The Plano Police Department Explorer Post 911 909 14 th Street Plano, Texas 75086-0358 Instructions Read these instructions
More informationClient Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No
: Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:
More informationKathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:
More informationSignature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
More informationAre You Pregnant and Thinking About Adoption?
FactSheet for Families March 2007 Are You Pregnant and Thinking About Adoption? Are you pregnant and not sure that you are ready or able to raise your child? If so, you might be thinking about placing
More information41. Name and address of your physician:
Providence Biblical Counseling Ministry - Personal Data Inventory Identification Data: 1. Name: 2. Phone: 3. Date: 4. Address/City/Zip: 5. Occupation: 6. Business Phone: 7. Cell Phone: 8. Email: 9. Birth
More informationArrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
More informationNEW PATIENT INFORMATION
NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY
More informationGONZABA MEDICAL GROUP PATIENT REGISTRATION FORM
GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************
More informationIf there are any questions, please feel free to contact us directly. We will do our best to make your home study experience as positive as possible.
Dear Home Study Applicant, Thank you for considering Adoption Makes Family as the agency to conduct your home study. We consider it a privilege to help families through the adoption process. Adoption is
More informationCLIENT QUESTIONNAIRE
Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:
More informationMaple Heights City Schools
Maple Heights City Schools ENROLLMENT OFFICE 5740 Lawn Avenue Maple Heights, Ohio 44137 ENROLLMENT OFFICE Phone: 216.587.6100, Ext. 3701 CHANGE OF ADDRESS REGISTRATION PACKET USE THIS PACKET FOR A CHANGE
More information19 TH JUDICIAL ADULT DRUG COURT REFERRAL INFORMATION
19 TH JUDICIAL ADULT DRUG COURT REFERRAL INFORMATION Please review the attached Drug Court contract and Authorization to Share Information. Once your case has been set on the adult drug court docket in
More informationACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE
ACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE By signing this document, I acknowledge that I have received a copy of Western Dental s Joint Notice of Privacy Practices. Name
More informationSocial Security # Date of Birth Age. Mailing Address City State Zip Code. Race Gender Height Weight Religious preference
VCU ADMISSION APPLICATION (804) 828-8822 Fax: (804) 828-9879 SERVICE REQUESTED 30-Day Evaluation 15-Day Evaluation Child s Name (please print) Nickname Social Security # Date of Birth Age Mailing CHILD
More informationMarian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
More informationAddiction Treatment Strategies
Patient Registration Legal Name First Middle Last Birth Date Address Street City State Zip Phone(s) Home Cell Work Is it ok to contact your cell? Yes No SSN Email (Used for appointment reminder) Known
More informationE-mail Address Marital Status S M W D. Have you or your spouse served in the U.S. Armed Forces Yes No
The following request is needed to help evaluate our ability to meet your needs, to assure full utilization of all benefits and assistance available to you and to provide statistical information pertaining
More informationPatient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Email Address: Primary Care Physician: Phone: Insurance ID #: Group #:
Patient Name: Date of Birth: / / Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Other Ethnicity: Not of Spanish/Hispanic Descent Spanish/Hispanic
More informationMONTESANO PHYSICAL THERAPY, INC. Patient Intake Information
MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S.
More informationClient Information Packet
Phone: 303-569-4588 Office locations: Email: tony@equinoxcounselingllc.com Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: www.equinoxcounselingllc.com Highlands Ranch, CO
More informationGarden City Police Department 107 N 3 rd Street PO Box 20 Garden City, MO 64747 (816) 773-8201
Garden City Police Department 107 N 3 rd Street PO Box 20 Garden City, MO 64747 (816) 773-8201 Applicant: Thank you for your interest for employment with the Garden City, MO Police Department. Enclosed
More informationPROBATE COURT USER GUIDE TERMINATION OF PARENTAL RIGHTS AND ADOPTIONS PUBLISHED BY OFFICE OF THE PROBATE COURT ADMINISTRATOR STATE OF CONNECTICUT
PROBATE COURT USER GUIDE TERMINATION OF PARENTAL RIGHTS AND ADOPTIONS PUBLISHED BY OFFICE OF THE PROBATE COURT ADMINISTRATOR STATE OF CONNECTICUT COMPLIMENTS OF YOUR LOCAL PROBATE COURT INTRODUCTION This
More informationGeorgia Advance Directive for Health Care
Georgia Advance Directive for Health Care In order to have a legal document that expresses your wishes for the health care you want to receive at the end of your life, you should complete a Georgia Advance
More informationNLSY79 Young Adult Selected Variables by Survey Year
I. LABOR MARKET EXPERIENCE VARIABLES A. Current labor force and employment status Survey week labor force and employment status Hours worked in survey week Hours per week usually worked Job search activities
More information