Some of the services we provide adoptive families include:

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1 Dear Prospective Adoptive Parent(s), Thank you for choosing Heart of Adoptions, Inc. to complete your adoption home study. We are pleased to share in your expectations for a successful adoption. Heart of Adoptions, Inc. is a full service, licensed adoption agency located in the state of Florida. It is our goal to provide professional and quality adoption services to families hoping to build their family through adoption. Some of the services we provide adoptive families include: Home Studies Post Placement Supervision Adoption Placement Services Interstate Compact Services Counseling Adoption Education Experienced Staff We understand that adopting a child can be overwhelming and emotionally challenging at times. Our knowledgeable staff is available to walk you step by step through the adoption process as you complete the necessary forms for your home study. One of our highly trained professionals will complete your home study, and after your child comes home, we will provide any legally required post placement supervision visits to insure that you and your new child are doing well. Your home study professional will provide you with guidance and support, as well as referrals for any additional services that your family may request. Please follow the enclosed detailed instructions to begin the home study process. We look forward to meeting your family soon and wish you much success on your adoption journey! Respectfully, Mary A. Wheatley, M.S. Executive Director

2 WHAT IS A HOME STUDY? A home study is a review of you, your spouse, and anyone else living in your home. It highlights items such as relationships, interactions with children, your neighborhood, and your childhood. Initially the home study process frightens some families until they actually complete one. We try to make the process both easy and relaxing. The home study helps the courts and our agency determine if a stable environment exists for a family to receive an adoptive placement. Collecting all the documents for the home study can be time consuming. Items such as a marriage license, driver s license, and birth certificate are required to legally confirm your identity. WHO SHOULD COMPLETE OUR HOME STUDY? Adoptive families enjoy the following advantages of our home study: Our home study can be used virtually anywhere in the United States. It is important to note that in many states, only home studies from licensed adoption agencies are accepted. In those situations, if you have selected someone other than a licensed agency to complete your home study, you may be required to have a qualified agency perform another home study for you. That means increasing your costs and possibly the wait to receive a child. We are able to complete home studies more quickly than most agencies. Our home study is less expensive than nearly all the other programs in Florida. We have a reasonable base fee for the home study and low fees for post-placement visits and home study updates, while other programs charge significantly higher fees for these services. WHAT ARE POST-PLACEMENT SUPERVISION VISITS? Post-placement supervision visits are follow-ups to the home study after a child is placed in your home. They consist of visits or contacts from a social worker to assess the status of the child and how the adoptive parents are adjusting. Once a child is placed in your home, please notify us immediately. Our agency will perform the required number of postplacement visits to ensure completion in time for finalization. While each state varies on post-placement visit requirements, on average 3 visits or contacts are required within the first 3 months after placement. Quarterly visits thereafter may also be required. WHAT IS A HOME STUDY UPDATE/ADDENDUM? A home study update/addendum is a required addition to the home study in the event of an address change, any major life changes or after a certain amount of time has passed (1 year in Florida). It is important that you notify us immediately following any events or life changes. WHAT IS THE DIFFERENCE IN AN INTERNATIONAL HOME STUDY? An international home study is somewhat different than a domestic home study. With an international home study, the requirements of your home state need to be met, in addition to the requirements of the Immigration and Naturalization Service and the foreign country. An international home study is a highly specialized style of home study that needs to be completed by a licensed adoption agency. If you are in need of an international home study rather than a domestic home study, us info@heartofadoptions.com for information on international home study services.

3 HOME STUDY INSTRUCTIONS STEP #1: Complete the following items and mail them in to our Tampa office, along with your payment for services: 1. DOMESTIC HOME STUDY AGREEMENT (form enclosed) 2. LOCAL CRIMINAL RECORD CHECK* you will need to go to your local sheriff s office and request a local criminal record check (instructions enclosed) on all household members age 12 or older. 3. STATE/FEDERAL FINGERPRINT CHECK* this report verifies your identity and state and national criminal record. You will need to go to an electronic fingerprint provider nearest you (instructions enclosed). All household members age 12 or older must be fingerprinted. There is a fee for each person being fingerprinted. 4. CENTRAL ABUSE HOTLINE RECORD SEARCH* & RELEASE OF INFORMATION (forms enclosed) this form is submitted by our agency to the Florida Department of Children and Families (DCF) protective services system to check for any involvement with the neglect, abuse or exploitation of a child. You must complete both pages of this form and mail the signed original to our agency. All household members, including anyone listed on page 1, must be listed on the top of page 2. You must also sign and mail the original of the DCF Release of Information that must accompany the abuse hotline record search. This should be completed and returned to us as soon as possible, since processing and clearance can take up to thirty days to receive back. 5. AFFIDAVIT OF GOOD MORAL CHARACTER* all adult household members must sign this (form enclosed) in front of a Notary Public and have it notarized. The signed and notarized original form should be mailed back to the agency. Please make additional copies as needed for other adults in the home. *If you have a child abuse/neglect history or have ever been arrested or have a criminal history of any king, you must provide dispositions and explanations of the events regardless of whether the arrest or charge was dropped or expunged from your record. 6. ADOPTION DISCLOSURE (form enclosed) 7. AUTHORIZATION FOR RELEASE OF INFORMATION (form enclosed) 8. CONTACT & IDENTIFYING INFORMATION (form enclosed) 9. BIOGRAPHICAL INFORMATION (form enclosed) each prospective adoptive parent should complete this narrative form separately. Please be sure to answer all questions thoroughly. 10. FIREARM SAFETY ACKNOWLEDGEMENT (form enclosed)

4 STEP #2: The collection of these documents can seem somewhat overwhelming at first, but in reality they are easy to obtain. You may items that only require a copy, but please mail in any documents that have an original signature. 1. FIVE (5) REFERENCE LETTERS provide five letters of reference addressing the following information about the prospective adoptive parent(s): the references name, address, address, and phone number; how long have they known you and in what capacity; how they feel you interact with children; and why they think you would be good parents. Two of your references may be relatives, but the other three must be non-relatives. Please have the reference mail their signed letter into our Tampa office. 2. BIRTH CERTIFICATE(S) submit a copy of each household member s birth certificate. If a prospective adoptive parent or household member was not born in the United States of America, also provide proof of citizenship or residency. 3. DRIVER S LICENSE(S) provide a photo copy of all adult household member s driver s license or identification card. 4. MARRIAGE LICENSE if applicable, provide a copy of your marriage record. 5. DIVORCE DECREE(S) if applicable, provide a copy of your divorce decree(s). 6. ADOPTION DECREES(S) if applicable, provide copies of all Final Judgments of adoption for all adopted children in the home. 7. MILITARY DISCHARGE(S) if applicable, provide a copy of your military discharge orders. 8. INCOME TAX RETURN provide a copy of the first two pages only of your latest income tax return. 9. INSURANCE VERIFICATION provide a photo copy of the health insurance card (front and back) that will begin covering your child at placement. 10. EMPLOYMENT VERIFICATION (form enclosed) submit to your employer for completion. If you are self-employed, please have a business partner or your tax accountant complete this form or write a letter. 11. HEALTH STATEMENTS FROM A PHYSICIAN (forms enclosed) you must have had a physical check-up within the last year. Have your primary care physician or a clinic complete the enclosed form for you and any other children or adult household members. Please make copies of the enclosed forms for additional household members as needed. 12. FAMILY MONTHLY BUDGET (form enclosed)

5 DOMESTIC HOME STUDY AGREEMENT Heart of Adoptions, Inc. agrees to conduct a home study investigation of the prospective adoptive parent(s). If HEART OF ADOPTIONS, INC. deems the prospective adoptive parent(s) unsuitable for adoption, HEART OF ADOPTIONS, INC. will inform the parent(s) and provide no additional services under this agreement. The determination regarding approval or disapproval of the prospective adoptive family is within the sole discretion of HEART OF ADOPTIONS, INC. The prospective adoptive parent(s) acknowledges that HEART OF ADOPTIONS, INC. makes no guarantees that the adoptive parent s home study will be approved or that an approved home study will result in a child being placed with the prospective adoptive parent(s). The prospective adoptive parent(s) agrees to hold harmless HEART OF ADOPTIONS, INC. in the event that they are not approved for the adoption of a child. The Adoptive Home Study Evaluation fee of $900 is due and payable upon request of services. Travel will be billed at $20 per hour for drive time plus mileage at the standard federal rate for visits made by the caseworker outside the city limits of the nearest office of HEART OF ADOPTIONS, INC. (Tampa, Naples or Orlando). Travel reimbursement for the caseworker, if applicable, will be reimbursed at the time of the home visit with a separate check payable directly to the caseworker. All fees are NON-REFUNDABLE. The prospective adoptive family is responsible for a $25 fee (plus costs, if any) for criminal or child abuse clearance requests from jurisdictions other than the jurisdiction of current residence. These additional clearance requests may be required in order to comply with our state licensing regulations and the Adam Walsh Act. This fee is NON- REFUNDABLE. The prospective adoptive family is also responsible for the fees associated with obtaining state/federal and local background checks and reports for all occupants in the household age 12 and older. This fee is payable directly to the police department, sheriff s office, and/or the electronic fingerprint provider utilized. This fee is NON-REFUNDABLE. During the home study process, HEART OF ADOPTIONS, INC. will advise the prospective adoptive parent(s) as to what adoption education, if any, will be required. We encourage all prospective adoptive parents to seek out as much adoption education as possible. Please explore the variety of adoption books available at We also recommend the following adoption education providers: Adoption Learning Partners ( and My Adoption Advisor ( All fees associated with required classes are the responsibility of the prospective adoptive parent(s).

6 HEART OF ADOPTIONS, INC. may require a psychological assessment or any other documentation deemed pertinent before approving or disapproving a prospective adoptive parent. All required psychological assessments and any other documentation are to be provided at the expense of the prospective adoptive parent(s). Although most home studies can be completed in 6-8 weeks, prospective adoptive families may request an expedited home study for emergency situations. The expediting fee of $250 is due and payable upon request of services and is NON-REFUNDABLE. The prospective adoptive parent(s) understands that there are certain legal procedures involved in the home study that cannot be avoided and could delay the final approval of the home study. Expedited home study requests are limited to situations where the prospective adoptive child s birth is imminent or placement of the child is of an urgent nature. The prospective adoptive family will receive one original copy of their home study report. They will also receive copies of HEART OF ADOPTIONS, INC. S agency license as issued by the Florida Department of Children and Families and all other supportive documentation required by the State where they are adopting, provided this information can be released by HEART OF ADOPTIONS, INC. In Florida, home study reports are valid for one year/twelve months from the date of completion. If the adoptive family does not receive placement of an adoptive child within one year/twelve months, a home study update will be needed. Any subsequent home study updates (usually completed if the initial report nears one year/twelve months old) conducted for the prospective adoptive family will be provided for the base fee of $500 (plus costs) and is due and payable upon request of services. This fee is NON- REFUNDABLE. Revisions or addendums to a home study (i.e. family relocates, someone new moves into home, etc.) after the final report has been written and approved is assessed at $100 per hour. This fee is due and payable at the time that the changes are made. This fee is NON-REFUNDABLE. Once you have an approved home study, you are able to serve as a temporary caretaker to children Heart of Adoptions, Inc. has matched with their forever family but the family is unable to take immediate placement. Please note these children are not available to be adopted by you, but instead need short term care. Please contact your social worker if you are interested in serving as a temporary caretaker. The placements can be days to weeks in length, but are typically very short-term. The Post-Placement fee of $200 per report is due and payable upon request of services. The agency will conduct a minimum of three visits after the placement of a child and, if needed, quarterly visits thereafter prior to the Petition for Adoption being filed. Travel for these visits will be billed at $20 per hour for drive time plus mileage at the standard federal rate for visits made by the caseworker outside the city limits of the nearest office

7 of HEART OF ADOPTIONS, INC. (Tampa, Naples or Orlando). Travel reimbursement for the caseworker, if applicable, will be reimbursed at the time of the visit with a separate check payable directly to the caseworker. This fee is NON-REFUNDABLE. I/We understand that in the course of the adoption process, certain documents considered to be confidential may be made available to persons for specific purposes related to the adoption process. I/We authorize HEART OF ADOPTIONS, INC. to release such information as deemed necessary. The withholding of information or the providing of incorrect information which is material to HEART OF ADOPTIONS, INC. S legal responsibility to investigate a prospective adoptive parent s suitability as an adoptive parent in connection with either existing or prospective adoption proceedings, or in anticipation of the placement of a child for adoption with applicant by HEART OF ADOPTIONS, INC. or another adoption professional, is grounds for the immediate termination of this agreement by HEART OF ADOPTIONS, INC. and a forfeiture of all payments made by the applicant to HEART OF ADOPTIONS, INC. up to the date of termination. Examples of material omission or misrepresentations of applicants which may prompt HEART OF ADOPTIONS, INC. to terminate the agreement are as follows: the withholding of information or the providing of incorrect information relating to an arrest or the alleged commission of a misdemeanor or felony, or any criminal record arising out of an arrest; the withholding of information or the providing of incorrect information concerning the applicant s biographical, socialeconomic or medical histories Information is deemed to be material under this agreement if it has a bearing on HEART OF ADOPTIONS, INC. S assessment that the adoptive parent(s) is qualified to adopt the child. The prospective adoptive parent(s) and HEART OF ADOPTIONS, INC. understand that because each party has entered into this agreement voluntarily, either party may terminate this agreement and the adoption process by giving written notice to the other party. A true and accurate copy hereof is as effective as an original for all purposes. Prospective Adoptive Parent (1) Date Prospective Adoptive Parent (2) Date

8 Local Criminal Record Check All household members age 12 or older must submit local background checks. The adoption home study process in the state of Florida requires a current local criminal background check on all household members age 12 or older. It will be necessary for you to go to your local Sheriff s Department and request a local background check. It may be wise to call your local Sheriff s Office first to see if there is a charge for this service or if there is any documentation you should bring with you. Should there be any reported criminal history, it will be necessary for you to obtain any and all reports and arrest dispositions, as well as provide a written explanation as to the circumstance involving law enforcement.

9 State/Federal Fingerprint Clearance NOTE: All household members age 12 or older must be fingerprinted. Fingerprints are done by appointment only at the location that you chose. Typically the appointments must be scheduled at least 24 hours in advance and may be prepaid by credit card, debit card, or e-check. HOW TO OBTAIN AN APPOINTMENT: STEP 1: Register online at or by calling STEP 2: When the appointment is scheduled, choose VECHS from the drop down list. If phone registration, inform the operator the request is for VECHS. STEP 3: Chose Volunteer and enter the Qualified Entity Number: Should there be any reported criminal history, it will be necessary for you to obtain any and all reports and arrest dispositions, as well as provide a written explanation as to the circumstance involving law enforcement.

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19 ADOPTION DISCLOSURE AND ACKNOWLEDGMENT OF RECEIPT OF ADOPTION DISCLOSURE THE STATE OF FLORIDA REQUIRES, PURSUANT TO CHAPTER 63 OF THE FLORIDA STATUTES, THAT THIS FORM BE PROVIDED TO ALL PERSONS CONSIDERING ADOPTING A MINOR OR SEEKING TO PLACE A MINOR FOR ADOPTION, TO ADVISE THEM OF THE FOLLOWING FACTS REGARDING ADOPTION UNDER FLORIDA LAW: 1. The name, address and telephone number of the adoption entity providing this disclosure is: HEART OF ADOPTIONS, INC. 418 WEST PLATT STREET, SUITE A TAMPA, FL The adoption entity does not provide legal representation or advice to parents or anyone signing a consent for adoption or affidavit of non-paternity and parents have the right to consult with an attorney of their own choosing to advise them. THIS MEANS THAT THE ADOPTION ENTITY'S ATTORNEYS, JEANNE T. TATE, DANELLE D. BARKSDALE, MARTHA A. CURTIS, STEVEN HURWITZ, NICOLE WARD MOORE, AND ROBERT L. WEBSTER III, DO NOT AND CANNOT REPRESENT THE BIRTH PARENTS. THE ADOPTION ENTITY'S FEES AND ATTORNEY FEES ARE PAID FOR BY THE PROSPECTIVE ADOPTIVE PARENTS. ADDITIONALLY, JEANNE T. TATE IS THE SOLE OWNER AND PRESIDENT OF THE ADOPTION ENTITY. 3. With the exception of an adoption by a stepparent or relative, a minor child cannot be placed into a prospective adoptive home unless the prospective adoptive parents have received a favorable preliminary home study, including criminal and child abuse clearances.

20 4. A valid consent for adoption may not be signed by the birth mother until 48 hours after the birth of the child, or the day the birth mother is notified, in writing, that she is fit for discharge from the licensed hospital or birth center. Any man may sign a valid consent for adoption at any time after the birth of the child. An affidavit of non-paternity may be executed before the birth of the minor. 5. A consent for adoption signed before the child attains the age of 6 months is binding and irrevocable from the moment it is signed unless it can be proven in court that the consent was obtained by fraud or duress. A consent for adoption signed after the child attains the age of 6 months is valid from the moment it is signed; however, it may be revoked up to 3 business days after it was signed. 6. A consent for adoption is not valid if the signature of the person who signed the consent was obtained by fraud or duress. 7. An unmarried biological father must act immediately in order to protect his parental rights , Florida Statutes, prescribes that any father seeking to establish his right to consent to the adoption of his child must file a claim of paternity with the Florida Putative Father Registry maintained by the Office of Vital Statistics of the Department of Health by the date a petition to terminate parental rights is filed with the court, or within 30 days after receiving service of a Notice of Intended Adoption Plan (if applicable). If he receives a Notice of Intended Adoption Plan, he must file a claim of paternity with the Florida Putative Father Registry, file a parenting plan with the court, and provide financial support to the mother or child within 30 days following service. An unmarried biological father's failure to timely respond to a Notice of Intended Adoption Plan constitutes an irrevocable legal waiver of any and all rights that the father may have to the child. A claim of paternity registration form for the Florida Putative Father Registry may be obtained from

21 any local office of the Department of Health, Office of Vital Statistics, the Department of Children and Families, the Internet websites for these agencies, and the offices of the clerks of the Florida circuit courts. The claim of paternity form must be submitted to the Office of Vital Statistics, Attention: Adoption Unit, P.O. Box 210, Jacksonville, FL There are alternatives to adoption, including foster care, relative care, and parenting the child. There may be services and sources of financial assistance in the community available to parents if they choose to parent the child. 9. A parent has the right to have a witness of his or her choice, who is unconnected with the adoption entity or the adoptive parents, to be present and witness the signing of the consent or affidavit of non-paternity. 10. A parent 14 years of age or younger must have a parent, legal guardian, or courtappointed guardian ad litem to assist and advise the parent as to the adoption plan and to witness consent. 11. A parent has a right to receive supportive counseling from a counselor, social worker, physician, clergy, or attorney. 12. The payment of living or medical expenses by the prospective adoptive parents before the birth of the child in no way obligates the parent to sign the consent for adoption. Acknowledgment of Disclosure and acknowledgment that I received a copy of this Disclosure for my records: Signature: Print Name: Date: Time: Signature: Print Name: Date: Time:

22 AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize the release of any information requested by Heart of Adoptions, Inc. to be utilized in determining my suitability to become an adoptive parent. I hereby grant permission for Heart of Adoptions, Inc. to obtain information from local, state or federal law enforcement agencies to help determine my suitability to serve as an adoptive parent. I understand, however, that a history of arrest reported by any of these agencies will not necessarily prohibit my application in the adoption program. Pursuant to Florida Statute (2)(a)5, I hereby authorize Heart of Adoptions, Inc. to make inquiry of the central abuse registry and tracking system in regard to the existence of any report of abuse, neglect, or exploitation and the results of any investigation pursuant hereto. Furthermore, I hereby grant permission for Heart of Adoptions, Inc. to obtain medical or psychiatric information from medical providers to help determine my suitability to serve as an adoptive parent. Lastly, I hereby authorize Heart of Adoptions, Inc. to disclose information obtained pursuant to this release to the following persons or organizations: Attorneys for adoptive parents; Attorneys for adoption agency; Agency for adoptive parents; Court in connection with adoption, as necessary; Interstate Compact on the Placement of Children, as necessary; and spouse/partner of adoptive parent. This authorization contemplates the sharing of information that might otherwise be protected and is intended to constitute a release of confidential and privileged information and communication. I understand that this authorization will remain in effect indefinitely unless I withdraw my consent in writing. Prospective Adoptive Parent (1) Signature Date Prospective Adoptive Parent (2) Signature Date Adult Household Member Date Adult Household Member Date

23 Contact and Identifying Information PARENT 1 NAME: Full Legal Name (First, Middle, Last) Maiden or A/K/A Social Security Number Date of Birth PARENT 2 NAME: Full Legal Name (First, Middle, Last) Maiden or A/K/A Social Security Number Date of Birth HOME ADDRESS: (Street, City, County, State, Zip) CONTACT INFORMATION: Home Phone Parent 1 Cell Phone Parent 2 Cell Phone Parent 1 Parent 2 IDENTIFYING & PHYSICAL INFORMATION: PARENT 1 PARENT 2 HEIGHT WEIGHT HAIR COLOR EYE COLOR COMPLEXION BODY STRUCTURE RACE ETHNICITY

24 PROSPECTIVE ADOPTIVE PARENT BIOGRAPHICAL INFORMATION Please answer the following questions as completely as possible in narrative form. Each adopting parent should complete their own narrative separately. Family Background Information: Parent s names, ages, location, health, and occupations. If deceased, state cause of death and when. Describe your relationship with your parents growing up and how it is today. Sibling names, ages, location, health, occupations, marital status, and children. Describe your relationship with your sibling(s) growing up and how it is today. Childhood: Describe where you grew up and what your childhood was like including your parents methods of discipline and how they interacted with you as a child. Explain if and how you will differ from them in how you were raised. How did your parents treat each other? Did your parents have a problem (i.e. alcoholism, violence, etc.) that may have affected your childhood development? If so, please describe the problem and how you coped. Education: List schools attended (high school and college), including location and years. What activities were you involved in, including special interests or major accomplishments. Describe degrees obtained. Did you work during this time? If so, describe. Employment: What is your job title? Describe your job duties. How long have you been in your current position? Do you have any plans to change employment in the near future? What is the salary structure? Are bonuses part of the structure? Clarify if salary is different than what tax return shows. Relationships: How/when did you meet your partner/significant other? If married, how long did you date before marriage? What attracted you to your partner? How do you and your partner relate to one another? What is your communication style and how are disagreements resolved? What is the best part about being together? If previously married/in significant long-term relationship, state date of marriage/relationship and dissolution. What is your relationship with your former partner? Explain how you generally get along with people. Do you have a small circle of close friends or many relationships? Who do you spend most of your time with? Who do you turn to for support during difficult times? Have you experienced any special, unusual or traumatic circumstances that impacted your development or how you relate to others? Children: If you have children, do they live with you? Are they from a previous marriage or relationship? If so, explain custody/visitation arrangements. Describe your relationship with your son(s)/daughter(s) and their personality. Do they know about your adoption plans? Are they supportive of your plans?

25 Please describe your child rearing philosophy? (i.e. what you hope to teach your child, how you will interact with your child, values you hope to pass along, etc). How do you plan to discipline your child? Have you had any formal education to prepare yourself and improve your abilities to parent a child? What is your childcare arrangement? Will you work or stay home with your child? Guardianship: What plans will you make for your child s future should something happen to you? Please list the name(s) of the individual(s) you plan to name as guardians and include their names, number of children, jobs, where they reside and why you chose them? If you have children at this time, is this arrangement already in a will? Religious/ Spiritual: Does religion play an important role in your life? If yes, describe. How will your religious beliefs be incorporated into your parenting? Do you plan on raising your child with a specific faith/religion? Home and Community: Describe your current housing arrangement (i.e. house, condo, apartment, etc.) including size, appearance, furnishings, # of smoke alarms, etc.? How long have you lived in this home? Describe your neighborhood (i.e. diverse, close-knit, etc.) Do you have a swimming pool? Do you have the proper safety fence? If your home is near a body of water, what steps have you taken to ensure water safety? Leisure/Recreational: Describe any special areas of interest or hobbies (i.e. art, books, crafts, shopping, exercising, outdoor activities, fishing, hunting, traveling, etc.) How often do you do these activities? Health: State any past or present health issues/disabilities. Have you ever received any psychiatric or therapeutic treatment? If yes, state when, along with outcome and current status. Explain any history of substance abuse or current problems with drugs/alcohol. Legal: Are you involved in any active cases (traffic, civil, criminal, probation, etc.)? If yes, describe in detail including dates, locations, and charges. Do you have any history of any legal issues? If yes, describe in detail including dates, locations, charges, and dispositions. Please write an explanation for each incident even if the charges were dropped. Thoughts about adoption: When did you first start thinking about adoption and why? If infertility is present, explain what medical consultation you received and your reaction then and now. Are you still pursuing medical treatment to conceive? Describe if and how you have resolved your feelings about infertility, or if you are still working through this process. How do you think you will feel towards the birth parents of your child? What adoption education have you received up to this point? Reason for Home Study: How were you referred to our agency? Please state your reason for completing a home study at this time. If you are currently matched with a birth mother or are matched with a born child, please describe how you came to be matched and/or why you wish to adopt this specific child.

26 PROSPECTIVE ADOPTIVE PARENT BIOGRAPHICAL INFORMATION Please answer the following questions as completely as possible in narrative form. Each adopting parent should complete their own narrative separately. Family Background Information: Parent s names, ages, location, health, and occupations. If deceased, state cause of death and when. Describe your relationship with your parents growing up and how it is today. Sibling names, ages, location, health, occupations, marital status, and children. Describe your relationship with your sibling(s) growing up and how it is today. Childhood: Describe where you grew up and what your childhood was like including your parents methods of discipline and how they interacted with you as a child. Explain if and how you will differ from them in how you were raised. How did your parents treat each other? Did your parents have a problem (i.e. alcoholism, violence, etc.) that may have affected your childhood development? If so, please describe the problem and how you coped. Education: List schools attended (high school and college), including location and years. What activities were you involved in, including special interests or major accomplishments. Describe degrees obtained. Did you work during this time? If so, describe. Employment: What is your job title? Describe your job duties. How long have you been in your current position? Do you have any plans to change employment in the near future? What is the salary structure? Are bonuses part of the structure? Clarify if salary is different than what tax return shows. Relationships: How/when did you meet your partner/significant other? If married, how long did you date before marriage? What attracted you to your partner? How do you and your partner relate to one another? What is your communication style and how are disagreements resolved? What is the best part about being together? If previously married/in significant long-term relationship, state date of marriage/relationship and dissolution. What is your relationship with your former partner? Explain how you generally get along with people. Do you have a small circle of close friends or many relationships? Who do you spend most of your time with? Who do you turn to for support during difficult times? Have you experienced any special, unusual or traumatic circumstances that impacted your development or how you relate to others? Children: If you have children, do they live with you? Are they from a previous marriage or relationship? If so, explain custody/visitation arrangements. Describe your relationship with your son(s)/daughter(s) and their personality. Do they know about your adoption plans? Are they supportive of your plans?

27 Please describe your child rearing philosophy? (i.e. what you hope to teach your child, how you will interact with your child, values you hope to pass along, etc). How do you plan to discipline your child? Have you had any formal education to prepare yourself and improve your abilities to parent a child? What is your childcare arrangement? Will you work or stay home with your child? Guardianship: What plans will you make for your child s future should something happen to you? Please list the name(s) of the individual(s) you plan to name as guardians and include their names, number of children, jobs, where they reside and why you chose them? If you have children at this time, is this arrangement already in a will? Religious/ Spiritual: Does religion play an important role in your life? If yes, describe. How will your religious beliefs be incorporated into your parenting? Do you plan on raising your child with a specific faith/religion? Home and Community: Describe your current housing arrangement (i.e. house, condo, apartment, etc.) including size, appearance, furnishings, # of smoke alarms, etc.? How long have you lived in this home? Describe your neighborhood (i.e. diverse, close-knit, etc.) Do you have a swimming pool? Do you have the proper safety fence? If your home is near a body of water, what steps have you taken to ensure water safety? Leisure/Recreational: Describe any special areas of interest or hobbies (i.e. art, books, crafts, shopping, exercising, outdoor activities, fishing, hunting, traveling, etc.) How often do you do these activities? Health: State any past or present health issues/disabilities. Have you ever received any psychiatric or therapeutic treatment? If yes, state when, along with outcome and current status. Explain any history of substance abuse or current problems with drugs/alcohol. Legal: Are you involved in any active cases (traffic, civil, criminal, probation, etc.)? If yes, describe in detail including dates, locations, and charges. Do you have any history of any legal issues? If yes, describe in detail including dates, locations, charges, and dispositions. Please write an explanation for each incident even if the charges were dropped. Thoughts about adoption: When did you first start thinking about adoption and why? If infertility is present, explain what medical consultation you received and your reaction then and now. Are you still pursuing medical treatment to conceive? Describe if and how you have resolved your feelings about infertility, or if you are still working through this process. How do you think you will feel towards the birth parents of your child? What adoption education have you received up to this point? Reason for Home Study: How were you referred to our agency? Please state your reason for completing a home study at this time. If you are currently matched with a birth mother or are matched with a born child, please describe how you came to be matched and/or why you wish to adopt this specific child.

28 Acknowledgement of Firearms Safety Requirements Florida Statue (safe storage of firearms required) states: A person who stores or leaves, on a premise under his or her control, a loaded firearm, as defined in s , and who knows or reasonably should know that a minor is likely to gain access to the firearm without the lawful permission of the minor s parent or the person having charge of the minor, or without the supervision required by law, shall keep the firearm in a securely locked box or container or in a location which a reasonable person would believe to be secure or shall secure it with a trigger lock, except when the person is carrying the firearm on his or her body or within such close proximity thereto that he or she can retrieve and use it as easily and quickly as if he or she carried it on his or her body. I/We and Acknowledge that I/we have read and understand this document. Prospective Adoptive Parent (1) Signature Date Prospective Adoptive Parent (2) Signature Date

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31 MEDICAL REPORT FOR PROSPECTIVE ADOPTIVE PARENT Name of person examined: DOB: I hereby authorize (name of medical provider) to release medical information contained on this form to Heart of Adoptions, Inc. Patient s Signature: Date: To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adults who are applying to become adoptive parents. PHYSICAL EXAMINATION Height: Weight: Blood Pressure: Current Medications and reason prescribed: Medication Reason MEDICAL HISTORY Are there any conditions that are chronic or progressive in nature that would interfere with this person s ability to care for a child to his/her age of majority? If so, please explain. If there are conditions that affect the patient s mental or emotional stability, please explain in detail: (use separate sheet if needed) How long have you known this patient? Physician Certification I certify that this patient is free from symptoms of communicable disease. Yes No If no, please explain: I certify that this patient has no physical or cognitive limitations that would prevent him/her from parenting. Yes No If no, please explain: Physician Signature: Printed Name: Address: Phone: Date:

32 MEDICAL REPORT FOR PROSPECTIVE ADOPTIVE PARENT Name of person examined: DOB: I hereby authorize (name of medical provider) to release medical information contained on this form to Heart of Adoptions, Inc. Patient s Signature: Date: To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adults who are applying to become adoptive parents. PHYSICAL EXAMINATION Height: Weight: Blood Pressure: Current Medications and reason prescribed: Medication Reason MEDICAL HISTORY Are there any conditions that are chronic or progressive in nature that would interfere with this person s ability to care for a child to his/her age of majority? If so, please explain. If there are conditions that affect the patient s mental or emotional stability, please explain in detail: (use separate sheet if needed) How long have you known this patient? Physician Certification I certify that this patient is free from symptoms of communicable disease. Yes No If no, please explain: I certify that this patient has no physical or cognitive limitations that would prevent him/her from parenting. Yes No If no, please explain: Physician Signature: Printed Name: Address: Phone: Date:

33 MEDICAL REPORT FOR CHILDREN IN THE HOME Name of child: DOB: Weight: Height: Hair Color: Eye Color: Is this child current on all immunizations: Please comment on the overall health and development of this child: How long have you known this patient? Physician Signature: Printed Name: Address: Phone: Date:

34 MEDICAL REPORT FOR OTHER ADULTS IN THE HOME Name of person examined: DOB: I hereby authorize (name of medical provider) to release medical information contained on this form to Heart of Adoptions, Inc. Patient s Signature: Date: To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adult household members, residing in a prospective adoptive home. PHYSICAL EXAMINATION Height: Weight: Blood Pressure: Current Medications and reason prescribed: Medication Reason MEDICAL HISTORY Are there any conditions that are chronic or progressive in nature that would interfere with this person s ability to be around or interact with a child? If so, please explain. If there are conditions that affect the patient s mental or emotional stability, please explain in detail: (use separate sheet if needed) How long have you known this patient? Physician Certification I certify that this patient is free from symptoms of communicable disease. Yes No If no, please explain: Physician Signature: Printed Name: Address: Phone: Date:

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