| Adoptive Father's Information |
| Have you ever failed to meet your child or spousal support obligation? |
|
| Has any child ever been removed from your care due to abuse or neglect? |
|
| Have you ever been deprived of parental rights or had your rights restricted? |
|
| Have you ever been charged with or accused of child abuse or neglect? |
|
| If yes, please explain* |
| * |
| Have you been accused of, or charged with, sexual abuse against another (even if there was no conviction)? |
|
| If yes, explain. |
|
| Have you been diagnosed with or received treatment for a mental health condition? |
|
| If Yes, please explain* |
| * |
| Do you have a history of drug use? |
|
| If yes, please state the drug that was used, the frequency and length of use, and your age at the time. |
|
| Have you ever been treated for drug or alcohol abuse? |
|
| If yes, please explain* |
| * |
| Do you have a history of domestic violence? |
|
| Do you have more than 4 traffic law violations? Please list. |
|
| Have you ever been denied a home study? |
|
| If yes, please explain* |
| * |
| Have you ever been given an unfavorable home study? |
|
| If yes, please explain* |
| * |
| Have you ever begun a home study that was never completed? |
|
| If yes, please explain* |
| * |
| Have you ever filed bankruptcy? |
|
| If yes, please explain* |
| * |
| Do you currently use any legal or illegal drugs, such as, marijuana? |
|
|
| Adoptive Mother's Information |
| Have you ever failed to meet your child or spousal support obligation?* |
|
| Has any child ever been removed from your care due to abuse or neglect?* |
|
| Have you ever been deprived of parental rights or had your rights restricted?* |
|
| Have you ever been charged with or accused of child abuse or neglect?* |
|
| If yes, please explain* |
| * |
| Have you been accused of, or charged with, sexual abuse against another (even if there was no conviction)? |
|
| If yes, explain. |
|
| Have you been diagnosed with or received treatment for a mental health condition?* |
|
| If Yes, please explain* |
| * |
| Do you have a history of drug use? |
|
| If yes, please state the drug that was used, the frequency and length of use, and your age at the time. |
|
| Have you ever been treated for drug or alcohol abuse?* |
|
| If yes, please explain* |
| * |
| Do you have a history of domestic violence?* |
|
| Do you have more than 4 traffic law violations? Please list.* |
|
| Have you ever been denied a home study?* |
|
| If yes, please explain* |
| * |
| Have you ever been given an unfavorable home study?* |
|
| If yes, please explain* |
| * |
| Have you ever begun a home study that was never completed?* |
|
| If yes, please explain* |
| * |
| Have you ever filed bankruptcy?* |
|
| If yes, please explain* |
| * |
| Do you currently use any legal or illegal drugs, such as, marijuana? |
|
|
