If You Are An Adoptive Parent, Please Complete The
Following Section:
If you have more than one adopted child, please complete a separate
copy of this section for each adopted child.
I am the ______adoptive mother _____ adoptive father
I am a single adoptive parent ______ Yes _____ No
This adopted child was ________________ years/months old when the adoption was finalized
This child was adopted in the United States: City/County/State__________________________________________________
This child was adopted outside the United States: Country/City__________________________________________________
I adopted this child through:
____ a county/state/federal government-affiliated organization
____ a religious-affiliated organization
____ a private organization
____ a charitable organization
____ a private attorney
____ my own family
____ friends
Other ________________________________
The race of this adopted child is
____ Caucasian ____ African American
____ Hispanic American ____ Oriental American
____ American Indian
Other ______________
This adoption cost approximately
____ nothing ____ $5,001-7,500
____ under $1,000 ____ $7,501-10,000
____ $1,001-3,000 ____ over $10,000
____ $3,001-5,000
I adopted this child while serving in the military ____ Yes ____ No
If yes, in which branch of the military _____________________
If during overseas service, in which country ________________
This adoption process, from initial request to final registration,
took approximately _______________ months/years to complete.
My desire was to adopt
___ any child ___ a healthy child
___ a boy only ___ a girl only
___ a specific race child ___ a mixed race child
___ a child of any race ___ a newborn child only
___ a child of any age ___ I had no expectations
___ a child with a health condition that I could help
I have ____ no other children
____ other adopted children (How many?)
____ other biological children (How many?)
Were your biological children born before ___ or after ___ the adoption of this child?
I was myself adopted ____ Yes ____No
Please Check Any Of The Following Statements That Apply To You:
____ This adopted child has always known he/she was adopted.
____ This adopted child will be told about his/her adoption as soon
as he/she can understand the concept.
____ This adopted child will be told about his/her adoption at age 18.
____ I will never tell this adopted child that he/she was adopted.
____ I know or know of the biological parent(s) and/or biological
family of this adopted child.
____ I will never allow the biological parent(s) and/or biological family
of this adopted child to contact the child.
____ I will allow the biological parent(s) and/or biological family
of this adopted child to establish contact after the adopted
child reaches the age of 18.
____ I do not know of nor have any information about
the biological parent(s) and/or biological
family of this child.
____ I will assist this adopted child to search and/or locate his/her
biological family whenever this adopted child expresses a
desire to locate and/or know about his/her biological family.
____ I will assist this adopted child to search and/or locate his/her bioligical family
when this adopted child reaches the age of 18 and expresses a desire to
locate and/or know about his/her biological family.
____ If this child expresses a desire to locate and/or know
about his/her biological family, I will not hinder the search.
____ If this child expresses a desire to locate and/or know about
his/her biological family, I will assist his/her
search in any way that I can.
Following Are A Series Of Subjective Statements That Deal With Feelings And Emotions.
Please Check Any And All Responses That Apply To You.
When this adopted child expressed a desire to discover his/her
biological parents and/or family, I felt
___ Threatened ___ Helpful _______________
___ Eager ___ Unloved _______________
___ Abandoned ___ Curious _______________
___ Receptive ___ Ready _______________
___ Resentful ___ Isolated _______________
___ Betrayed ___ Supportive _______________
When this adopted child located his/her biological parent(s)
and/or family, I felt
___ Relieved ___ Hostile _______________
___ Curious ___ Hopeful _______________
___ Proud ___ Selfish _______________
___ Threatened ___ Receptive _______________
___ Secure ___ Left out _______________
Please Answer By Checking Yes Or No To The Following Statements:
Based on my adoption experience with this child,
I would recommend to other potential adoptive families that
-adoption is wonderful. ______Yes ______No
-adoption is a risk. ______Yes ______No
-adoption is fulfilling. ______Yes ______No
-adoption is a no-win situation. ______Yes ______No
Based on my adoption experience with this child,
I would recommend to other potential adoptive families that
-they tell their adopted child about the adoption as soon
as the child can understand the concept. ______Yes ______No
-they never tell their adopted child about the adoption. ______Yes ______No
-they tell their adopted child about the adoption when the
child reaches the age of 18. ______Yes ______No
Based on my adoption experience with this child,
I would recommend to other potential adoptive families that
-they never offer any information about the biological parent(s)
and/or family to the adopted child. ______Yes ______No
-they withold any information about the biological parent(s)
and/or family until the adopted child reaches the age of 18.______Yes ______No
-they give the adopted child any and all information they
possess regarding the biological parent(s) and/or family
whenever they are asked by the adopted child. ______Yes ______No
Please Give Us Your Personal Comments On Any Aspect Of Your Adoption Experience:
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