First Name *
Last Name *
Spouse First Name
Spouse Last Name
Are you currently adopting through ADOPT ABROAD?
Where are you in the adoption process?
Educational Background (Mom)
Educational Background (Dad)
Annual Household Income
Household Net Worth
Number of Previous Marriages (Mom)
Number of Previous Marriages (Dad)
Number and Ages of Children in the Home
List all current and past diagnosed health conditions
List all medications you are currently taking
List all past surgeries with dates and recovery status
Do you have any arrests, regardless of outcome?
Please provide additional information including dates, type of charge, description of events leading to the arrest and outcome of the arrest
Have you ever terminated your parental rights or had your parental rights terminated?
Have you ever placed a child for adoption?
Home study Agency
Home study Date
Age Range (check all that apply)/ MONTHS
12 Months or Younger
We will consider parenting a child diagnosed with only minor/correctable medical needs
We will consider a child that may require long term treatment and/or care
We will consider a child who has more than one special need
We would accept a healthy child over the age of 8 years old
In the following section, please review each medical need and only check the medical needs that you would
a child with the following medical conditions (check all that apply):
In the following section, please review each medical need and only check the medical needs that you would seriously consider. A description of each need and explanation of each item listed can be found in our Waiting Child Medical Glossary. Please use this glossary for reference as you complete your checklist.
Thalassemia B intermedia
Thalassemia B major
Developmental Delay (Gross motors skills)
Developmental Delay (Global)
Developmental Delay (Language)
Developmental Delay (Sozial Skills)
Central Nervous System
Cerebral Palsy (mild)
Cerebral Palsy (moderate)
Cerebral Palsy (severe)
Spina Bifida (post-operative)
Spina Bifida (pre-operative)
Cleft lip and palate, unilateral (pre-operative)
Cleft lip and palate, unilateral (post-operative)
Cleft lip and palate, bilateral (post-operative)
Cleft lip and palate, bilateral (pre-operative)
Cleft lip and palate, Cleft lip (II-III degree)
Cleft palate (III degree)
Deformity of fingers and/or toes
Complete absence (More than 1 limb)
Complete absence (1 limb)
Clubbed hands (Bilateral)
Clubbed hands (Unilateral)
Clubbed feet (Bilateral)
Clubbed feet (Unilateral)
Brachial Plexus Injury
Requires assistance to walk (not wheelchair bound)
Scoliosis (slight curvature)
Scoliosis (significant curvature)
Underdevelopment/maldevelopment (1 limb)
Underdevelopment/maldevelopment (More than 1 limb)
Hearing loss (Partial)
Hearing loss (Complete)
Vision loss (Partial)
Vision loss (Complete)
Albinism (also involves vision)
Burns (involves significant scarring)
Nevus/hairy nevus (Small)
NeNevus/hairy nevus (Large)
Nevus/hairy nevus (Multiple)
Capillary malformation (Port wine stain)
Please be as detailed as possible in answering the questions below, as this information will be reviewed to determine the best match for your family and the child.
Why does your family wish to pursue a Waiting Child adoption?
Describe any experience your family has with individuals with special needs (personal and professional)
What types of resources are available to your family that will help you meet the needs of a special needs and/or older child? Please include medical resources as well as family and community support.
How will you handle any future conditions that may arise as a result of the special medical need? Does your health insurance cover pre-existing condition? If not, how do you plan to finance medical treatment for the child?
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