| | Husband | Wife |
| Age: | | |
| Race: | | |
| Date of Marriage: | |
| Previous Marriage(s): | | |
| Reason for ending: | | |
| Number of Children from Previous Marriage(s): | | |
| Religious Affiliation: | | |
| Active Member: | Yes No | Yes No |
| Occupation: | | |
| Annual Income: | | |
| Health: | | |
| Is infertility an issue?: | Yes No | Yes No |
| |
| Age and sex of children in your family. (Indicate if biological or adopted and if adopted, what race or nationality.): |
| Career plans for parents after adoption (i.e., take leave-of-absence, return to work, full-time, part-time, or stay at home): |
| Travel - If required, could you and/or your spouse travel?: Yes No |
| Maximum Time you could be away: |
| Finances - Fee range willing to consider for your adoption?: |
| Note: Most of our sources' fees range from $28-40K for Caucasian, Hispanic, or Asian, $15-25K for minority (i.e., African American or bi-racial, part African American). Please indicate the fee range you would consider. It is not necessary to have all funds available when you begin your adoption process. |
| |
| Description of child you would consider for adoption: |
| Age of Child: | Infant-1 Year 1-3 Years 3-5 Years |
| How many children would you feel comfortable accepting?: | 1 Child Twins Siblings |
| |
| Race of Child |
| African American: | Yes No Would Consider |
| African American/Caucasian: | Yes No Would Consider |
| American Indian: | Yes No Would Consider |
| American Indian/Caucasian: | Yes No Would Consider |
| Asian: | Yes No Would Consider |
| Asian/African American: | Yes No Would Consider |
| Asian/Caucasian: | Yes No Would Consider |
| Caucasian: | Yes No Would Consider |
| Filipino: | Yes No Would Consider |
| Hispanic: | Yes No Would Consider |
| Hispanic/African American: | Yes No Would Consider |
| Hispanic/Caucasian: | Yes No Would Consider |
| |
| Most of our sources place newborns from the United States. If you are interested in adopting a child internationally we can assist with this as well. Please indicate countries that you have specific interest in pursuing. |
| |
| Level of openness between Adoptive Parents and Birth Parents (Most of our clients are open to "semi-open confidential." They are willing to prepare a non-identifying profile; open to meeting birth parent before the adoption; and sharing letters/pictures through the agency after the adoption. Please comment on your comfort level with the above): |
| |
| Additional Information |
| Please tell us anything else about yourself or the child you would like to adopt that will assist us in finding appropriate sources for you. What is most important to you in pursuing this adoption (i.e., time frame, cost, age of the child, your ability to travel, etc.)?: |
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