PRELIMINARY SCREENING FORM*



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Preliminary Application

Date: ______________________

Full Name: DOB:

Status: ___Married ___Widowed ___Divorced ___Single (Date of Marriage):______________

Spouse’s Full Name: DOB:

Address:

City: County: State: Zip:

Home Telephone: Fax: ____________________

Your Home: (Apartment, Condo or House) ___________How long?_________ ( )Rent ( )Own

Prospective Adoptive Parent’s Information

Employer ________________________ Position: ________________Work Phone__________

Annual Salary _____________________Work Address:

Cell Phone: Email Address: _____________________________

Religion _____________________Race___________________ Education__________________

Height: Weight: Nationality:

Previous Marriage(s):___________________Date: Dissolution:

Prospective Adoptive Parent’s Information

Employer ________________________ Position: ________________Work Phone__________

Annual Salary _____________________Work Address:

Cell Phone: Email Address: _____________________________

Religion _____________________Race___________________ Education__________________

Height: Weight: Nationality:

Previous Marriage(s):___________________Date: Dissolution:

Children:

Name Birth Date By Birth or Adoption Resides With Nationality/Race

Please complete the following questions. Use additional paper if needed.

1. How did you hear about Florida Adoption Center LLC ________________________________________________________________________

2. Do you have a completed home study? ________When:______ By:_________________

3. Why have you chosen to pursue adoption as a means of growing your family?

________________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

4. Have you previously or are you undergoing fertility testing? List any alternate methods of conception (i.e. in vitro fertilization or artificial insemination)? Please explain. Provide name of Physician(s) and dates when medical treatment was discontinued____________

________________________________________________________________________

5. Please discuss any medical problems or chronic illness of either spouse. Provide name of physician(s). Please include past or current treatment for psychiatric or chemical dependency problems______________________________________________________

________________________________________________________________________

6. Please describe the type of child you feel would fit into your family at this time. Include age range, race(s) and health. Adoption Preference: No Preference ____Undecided____

Race: Caucasian____ Hispanic____ African-American ____Bi-Racial ___Other:______

Age: Newborn ___Older child (Age Preference_____) Gender: Male ____Female____

Special Needs: Y N Health Issues: Y N Drug Exposed: Y N

Willing to accept: Marijuana___ Cocaine___ Methadone___ Alcohol____ Tobacco____ Opiates___ Methamphetamines___ Barbiturates___ Psychotropic___ Benzodiazepine___

________________________________________________________________________

________________________________________________________________________

We, the adoptive family, willingly submit the $250.00 fee with this application. We acknowledge that this preliminary application fee is non-refundable. Please make your check payable to Florida Adoption Center LLC. and mail to: 1600 Sarno Road, Bldg. A. Suite 8, Melbourne FL 32935.

Signature _______________________________________________ Date: _________________

Signature _______________________________________________ Date: _________________

**Please email a recent photograph of your family to Andrea@ when you submit this Preliminary Application and Preliminary Application fee. **

If this form is not returned within 30 days from the original mailing or receipt, we will assume you are no longer interested.

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