OPEN ARMS ADOPTION SERVICES, INC.



OPEN ARMS ADOPTION SERVICES, INC.A Non-Profit Louisiana Licensed Child Placing Adoption Agency7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105 Telephone: 318-798-7664 Fax: 318-861-1710 dmeapc@ D. Missy Everson, LCSW, DCSW, Executive DirectorAPPLICATION PACKET INSTRUCTIONSPrior to printing out, please check to make sure the pages realigned correctly. The attached Application Packet contains the following: Application (3 Pages) Explanation of Background Checks (1 Page) Required Documents List (1 Page) Medical Release/Physician’s form (2 Pages) Child Medical (if you have a child in the home – 2 Page)References Release/Contact Information (1 Page) (One relative from each side of the family, and 4 unrelated persons who know both of you, plus at least one current employer/supervisor) Duty To Disclose Form (1 Page) Contract (2 Pages)1 - Please complete the Application, Reference Release/Contact Information, and Contract; sign all and return to us with your home study fee (listed in contract) made payable to Open Arms Adoption Services, Inc. 2 - Arrange your doctors’ appointments, complete and sign the tops of your medical forms, and bring this form to your physician’s appointment to be completed and signed by the doctor or NP.3 - Gather and make a copy of each of the documents on the Required Documents List. 4 – Hold everything from 2 and 3 until the first meeting with your social worker. We do not want to have any of these lost in the mail.****************************************************************************************Once we receive your Application, Contract, Fee, and References Release, we will contact you to arrange the home visit and interview appointments. We will then send you by e-mail the forms to complete for each interview/visit. Please feel free to email a reminder to me if you do not receive once the appointment times are arranged.At any point please let us know if you have any questions. We look forward to working with you during your adoption home study, and beyond. You are on your way!APPLICATION FOR HOME STUDY SERVICESPlease write very legibly Husband Wife Full Legal Names: *** * Called: *** * Date of Birth/Age: *** * Place of Birth: *** *Height and Weight: *** *Hair/Eye/Complexion: *** *Social Security #: *** * Driver’s License # / State: *** *Date of Marriage/Years Married: *Place of Marriage/Parish/County: * Previous Marriages: *** *Citizenship: *** * Ancestry/Ethnicity *** *Religion: *** *Education/Degree in: *** * College/University: *** *Location/City/State: *** *Occupation: *** *Current Employer: *** * Location: *** *If military, rank *** *Years of service: *** * Page 2 – Application Home Address and Parish: *Home Phone: * Cell Phones: *** * E-Mails: *** * *********************************************************************************************** Children in Home:Name and DOB: *Name and DOB: * Name and DOB: *Children Out of the Home, Including Adult Children: Name and DOB: *Name and DOB: *Name and DOB: * ********************************************************************************************** Previous Adoption Information Have you applied to adopt anywhere else currently or in the past? If so, please give details (where, when, outcome, etc.).Have you ever been turned down by an agency or attorney for any reason other than too many families on the waiting list? If so, please give details.Please give any additional information and discuss your prior adoption experience.Page 3 – Application Previous Address: The federal Adam Walsh Act requires a list of every residence since age 18 on both applicants (city, parish/county, state, and in what years). Child abuse background checks will be conducted in all the states in which you have resided since age 18. Please list below or on separate sheet, or sign if applicable: Husband: I have never lived or worked outside of Louisiana since age 18 Sign _______________________________ Wife: I have never lived or worked outside of Louisiana since age 18 Sign __________________________________ PLEASE PRINT LEGIBLYName when lived there City County/Parish State Year/Years We have completed this application truthfully and we feel ready to start the adoption process.Signed,____________________________________________ ____________________________________________ Husband Date WifeDatePERSONAL DISCLOSURE AGREEMENTAnd DUTY TO DISCLOSEI (We) understand that the home study process entails a duty to disclose and discuss all instances of substance abuse, mental illness, domestic violence, previous marriages, child neglect or abuse, and criminal arrest, charges, or convictions. I (We) understand that these disclosures do not necessarily disqualify me (us) as an adoptive parent(s), but not disclosing and having such information found out by the social worker, the Court, the Citizenship and Immigration Services, or the Department of Children and Family Services, may disqualify me (us) as an adoptive parent(s), may result in the denial of the placement of a child, or the denial of the immigration of a child, or the denial of the finalization of an adoption, or the removal of a potential adoptive child, or the denial of custody rights. I (We) further understand that I (we) have a duty to disclose all such information, and understand that if I(we) have not disclosed such information, I (we) will not be entitled to a refund of any money already paid for any adoption or custody services.I (We) also understand that even if I (we) have disclosed such information, that if I (we) choose to complete the home study process and submit the completed approved study to the Court, another agency, attorney, or USCIS, that this agency cannot guarantee the decisions of the other agency, attorney or any Court, or the USCIS, and therefore, any fees paid to date will not be returned regardless of outcome.*********************************************************************************I (We) have read, understood, been given the opportunity to ask questions, and have agreed to disclose all the above information. This disclosure is being signed with full knowledge that there is a penalty of perjury in knowingly withholding information or giving false information in an adoption or custody home study. Signed,_________________________________________ _______________Parent Applicant Date_________________________________________ _______________Parent Applicant Date Explanation of Background ChecksThere are three different background checks that we will need for your home study. These are for each parent adopting as well as each household member who is 17 or older. 1 – State Police Criminal Check – These are conducted through biometrics with the Sheriff’s office in the parish in which you reside. The agency must make an appointment with them before you can have this done. Once we begin the home study, we will arrange the appointment. The results will be sent directly to a site that we are authorized to access about 3-5 days later. The cost generally runs about $45 per person paid to your parish’s Sheriff’s office. Please retain your receipt. 2 – Child Abuse Registry Check – These are conducted by the LA Dept. of Children and Family Services through us after you have completed the release during the home study process. There is no charge for the initial registry check, but we charge a $5.00 service fee per family for each subsequent annual check needed. It takes about 2-4 weeks for them to return the results to us. If you have lived in other states, some states do charge for this, and we will let you know what the fee is, so that you can reimburse the agency. These child abuse checks take various times to conduct so please be advised that we cannot issue the study until all are returned.3 – FBI – You will arrange these yourself by going to . Follow the prompts, arrange an account for each of you as directed, and arrange a date for biometrics at a location nearest to you. You will be notified when the results are ready for you to access, usually 24-72 hours after submission. Please read their FAQs, as results are only available for a few days. Print out several copies of the results once you access them. We need at least one to three copies, and you should keep a copy as well. Cost is $50 per person to Fieldprint. Do not complete your FBI until you have the home visit appointments arranged, as they expire annually.*********************************************************************************If you should have a conviction on your record, then ask the Clerk of Court from the Court in which the hearing/trial was held for a copy of the Disposition of the Case and or the Court Minutes. This must be included in the home study. There may or may not be a charge for the copy you request from the Clerk of Court. And some Courts do generic minutes, so you will have to get further specific paperwork from the court to detail the Disposition. Louisiana Criminal Code Article 894 regarding expungement still allows the arrest to come up in your record and then lists the expungement, so the court minutes are still needed. ADOPTION HOME STUDYREQUIRED DOCUMENTS LIST1 – Certified or copies of certified Birth Certificates on each parent and child in the household2 – Certified or a copy of a certified filed copy of your Marriage Certificate with filing date and/or book and page number, or other identifying file number3 – If married previously, a copy of a certified copy of the Death Certificate or the Divorce Judgment is required.4 – Copies of your Social Security cards - applicant(s) only5 – Copies of your Driver’s Licenses – make sure it is not expired (copy also the back if there is a renewal sticker), and that the address is your current address unless you travel with a military ID6 – If working toward an international placement, color copies of your Passports7 - The last three years of the front and back of your IRS 1040 tax forms; just the 1040, not the other forms, unless self-employed, then copy the Schedule C or E also8 – Insurance verification for: (please do not copy entire policies, only a facesheet or appropriate page with info needed)Home: must have your name, address, insurance company name, policy number, and the expiration date. Health: must have your name, insurance company name, policy number, and verification that an adopted child will be covered/how/when. Auto: must have your name, insurance company name, policy number, car description, and expiration date. Life: must have the coverage amount and type (whole, term, etc.) of insurance, and the beneficiary shown.Disability: must have your name, insurance company name, policy number, and a brief description. This could be a copy of the appropriate page from your insurance handbook, or a letter from your insurance administrator.9 – Verification that a retirement plan is in place 10 - If you have pets, a veterinary statement (shot record, detailed bill, etc.) that all the shots are current on each animal11 – Copies of your wills are not necessary, but I must make the statement regarding guardianship, that the guardianship plan will be reflected in your wills after placement. It is highly recommended that you make arrangements for your wills if you do not already have them in place.OPEN ARMS ADOPTION SERVICES, INC.A Non-Profit Louisiana Licensed Child Placing Adoption Agency7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105 Telephone: 318-798-7664 Fax: 318-861-1710 dmeapc@ D. Missy Everson, LCSW, DCSW, Executive DirectorADOPTIVE PARENT'S MEDICAL REPORTNAME:____________________________________________ DOB: ____________________ Age_________ SS#____________________________******************************************************************************Dear Doctor___________________________,You are hereby authorized to complete this form on me, and to give Open Arms Adoption Services, Inc. any additional information as requested concerning my health and infertility status. Signed, ________________________________ *************************************************************************************** Date of examination:_____________________Height:________ Weight: ________lbs. Blood Pressure:_____/____* Is this patient free of all communicable diseases? _________ If not, please detail. _________ ______________________________________________________________________________* Has the patient been treated for any acute illnesses or conditions within the last six months? ______ If so, please describe, including medication, and if resolved. ____________________________________________________________________________________________________*Is the patient being treated for any chronic illnesses or conditions? ______ If so, please give the DX, PX, TX, and if on medication, please list name, dose, reason, and expected duration. ____________________________________________________________________________________________________________________________________________________________*Has the patient received a DX and TX for infertility? ______ If so, please describe current status. ________________________________________________________________________ *Is it your opinion that this patient is in good physical, mental and emotional health and capable of parenting an adoptive child? ___________ If not, please comment. _____________________ ______________________________________________________________________________*Do you recommend adoption? ____________________________________________________ Signed, _____________________________M.D. Print Name______________________________ Or Stamp Address: _______________________________OPEN ARMS ADOPTION SERVICES, INC.A Non-Profit Louisiana Licensed Child Placing Adoption Agency7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105 Telephone: 318-798-7664 Fax: 318-861-1710 dmeapc@ D. Missy Everson, LCSW, DCSW, Executive DirectorADOPTIVE PARENT'S MEDICAL REPORTNAME:____________________________________________ DOB: ____________________ Age_________ SS#____________________________******************************************************************************Dear Doctor___________________________,You are hereby authorized to complete this form on me, and to give Open Arms Adoption Services, Inc. any additional information as requested concerning my health and infertility status. Signed, ________________________________ ******************************************************************************Date of examination:_____________________Height:________ Weight: ________lbs. Blood Pressure:_____/____* Is this patient free of all communicable diseases? _________ If not, please detail. _________ ______________________________________________________________________________* Has the patient been treated for any acute illnesses or conditions within the last six months? ______ If so, please describe, including medication, and if resolved. ____________________________________________________________________________________________________*Is the patient being treated for any chronic illnesses or conditions? ______ If so, please give the DX, PX, TX, and if on medication, please list name, dose, reason, and expected duration. ____________________________________________________________________________________________________________________________________________________________*Has the patient received a DX and TX for infertility? ______ If so, please describe current status. ________________________________________________________________________ *Is it your opinion that this patient is in good physical, mental and emotional health and capable of parenting an adoptive child? ___________ If not, please comment. _____________________ ______________________________________________________________________________*Do you recommend adoption? ____________________________________________________ Signed, _____________________________M.D. Print Name______________________________ Or Stamp Address: ________________________________ OPEN ARMS ADOPTION SERVICES, INC.A Non-Profit Louisiana Licensed Child Placing Adoption Agency7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105Telephone: 318-798-7664 Fax: 318-861-1710 dmeapc@ D. Missy Everson, LCSW, DCSW, Executive DirectorCHILD’S MEDICAL REPORTFamily Name: ___________________________ Today's Date: ______________Child's Name: ________________________________ DOB: _________________********************************************************************************Dear Doctor ___________________:You are hereby authorized to complete this form on my child and to give Open Arms Adoption Services any additional information as requested concerning his/her physical or medical condition. Signed, ______________________________________ Parent ********************************************************************************Date of examination: ________________Height/length: ___________ Weight: _____________ Temp.: ____________1. Are all immunizations on schedule? Yes No (Please attach a copy of the immunization record). Allergic reactions? (Please explain). ____________________________________________________ 2. Is this child free of all communicable diseases? Yes No If "No", what does this child have and what is the treatment? ____________________________________________________________________________________ 3. Has this child been treated for any acute conditions within the last six months? Yes No If "Yes", please give Dx, Tx, medications, if resolved, etc. ______________________________________________________________________________________ ______________________________________________________________________________________ Child Medical Form – Page 24. Is the child being treated or tested for any chronic conditions? Yes No If "Yes", please give Dx, Px, Tx, medications, recommendations, etc. __________________________________________________________________________________ 5. Does this child have any medical allergies? Yes No If "Yes" please list: _________________________________________________________________ 6. Is this child developing within normal limits? Yes No Comments? ________________________________________________________________________ 7. Do you consider this child to be in good physical and emotional health? Yes No Comments? ________________________________________________________________________ 8. Is it your opinion that this child is receiving good medical care? Yes No Comments? _______________________________________________________________________ 9. Is it your opinion that this child is receiving proper nurturing and parenting? Yes No Comments? ________________________________________________________________________10. Any health recommendations or additional comments? Yes No Comments? ________________________________________________________________________ Signed, ______________________________M.D. Print Name _______________________________ Address __________________________________ Please return to the above address or give to the parent to return to us. Thank you. REFERENCE RELEASE FORMADOPTION HOME STUDYI (we) request that the following persons be contacted as references regarding my (our) application to adopt a child. I (we) understand that the content of these responses will be confidential. SIGN:****** Husband: ________________________________ Date: ___________****** Wife: ___________________________________ Date: ___________ ***************************************************************************PERSONAL (6): PLEASE PRINT LEGIBLYName: ____________________________________________________ (Relative of husband)Address: ____________________________________________________ ZIP: ____________Email: ____________________________________________________ Name: ____________________________________________________ (Relative of wife)Address: ____________________________________________________ ZIP: __________Email: ____________________________________________________ Name: ____________________________________________________ (Unrelated to either)Address: ____________________________________________________ZIP:_____________Email: ____________________________________________________Name: ____________________________________________________ (Unrelated to either)Address: ____________________________________________________ ZIP: ___________Email: ____________________________________________________Name: ____________________________________________________ (Unrelated to either)Address: ____________________________________________________ ZIP: ___________Email: ____________________________________________________Name: ____________________________________________________ (Unrelated or use pastor if desired)Address: ____________________________________________________ ZIP: ___________Email: ____________________________________________________ EMPLOYER of HUSBAND: (Please do not put your HR Dept.)Name of Supervisor: __________________________________________Title: _______________________Business Name: __________________________________________________________________________Mailing Address: _________________________________________________________ ZIP: ___________EMPLOYER OF WIFE: (Please do not put your HR Dept.)Name of Supervisor: __________________________________________Title: ________________________Business Name: ___________________________________________________________________________Mailing Address: _________________________________________________________ ZIP: ____________Grown Child 1 (if applicable):Name: ____________________________________________________ Child of: _____________________Address: _________________________________________________________________ ZIP: ____________Email: ____________________________________________________ Grown Child 2 (if applicable):Name: _____________________________________________________ Child of: ____________________Address: _________________________________________________________________ ZIP: ____________Email: ____________________________________________________ OPEN ARMS ADOPTION SERVICES, INC.A Non-Profit Louisiana Licensed Child Placing Adoption Agency7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105Telephone: 318-798-7664 Fax: 318-861-1710 dmeapc@ D. Missy Everson, LCSW, DCSW, Executive DirectorADOPTION/CUSTODY HOME STUDY CONTRACTWe request that a pre-placement adoptive/foster care/custody home study be conducted by Open Arms Adoption Services, Inc., A Louisiana Licensed Non-Profit Child Placement Adoption Agency, in fulfillment of the requirements of the Louisiana Children's Code, Section 11, Chapter 2, Articles 1171-1174, and the Louisiana Administrative Code according to the 2010 Legislative Act 64, Title 67, Part V, Subpart 8, Chapter 73, Article 7315. The Home Study shall include the following: 1 – A minimum of two home visits, plus an additional home or office visit are required, including separate face-to-face interviews with each member of the household. All adult members of the household must be present during the home visits. Children may be interviewed in the home or office.2 – New FBI and State Police criminal background checks, and child abuse clearance checks for each applicant and each adult member of the household are required. Child Abuse checks must be requested and received from each state any adult in the household has resided in since age 18, as required by the federal Adam Walsh Act. 3 - Evidence of a physical examination performed within six months of the study, verifying that each person in the household suffers no communicable disease, acute or chronic condition, illness or disability that would interfere with the family's ability to parent a child. Forms are provided by the agency; applicants may go to their own physician.4- The names and mailing addresses of seven references, specifically six personal references, including one relative from each side of the family, and a reference from at least one current employer. The names and addresses of the references will be provided by the applicants. The agency will send forms for the references to complete; they do not need to write a letter. A pastoral reference is required by some placing agencies, but is not required by Louisiana. All grown children who no longer reside with the applicants must be contacted by the agency in addition to the required references, and their names and addresses must be provided. 5- Copies of certified birth and marriage certificates, as well as specific legal, financial, medical, and insurance documents as required on the Documents List, will be provided by the applicants.We understand that upon completion of the study, we will be notified in writing within thirty days of the status of the study, either favorable or disapproved. If favorable, a Certificate of Adoption will be issued which will qualify applicants to adopt in Louisiana, or from out of state in accordance with law, and will be valid for two years, with updates required with any major changes (job, residence, family constellation, etc.), and at least once a year. In the case of Custody, a formal recommendation will be made directly to the applicable requesting court.PAGE 2We understand that the cost for the completion of a domestic infant/toddler adoption study is $1975 plus mileage at the current IRS mileage rate per mile. We understand that the cost for the completion of any other adoption home study, and all custody home studies, begins at the rate of $2500, and increases depending on the age and number of children, any special needs preparation and assessments needed, and/or other variables including the requested items on the other state’s placement checklist, or the international agency’s placement list and country’s checklist, or any new USCIS requirements, or the Court Checklist for Custody Studies, plus mileage at the current IRS mileage rate. The home study fee is due at application. The mileage charge will be billed after the last home visit.Should we withdraw the home study application, we understand that a partial refund will be made, prorated according to the services already rendered. We understand that the cost of fingerprinting, background checks, extra persons in the home, and the physicals will be the responsibility of the applicants. The costs for the home study and related fees shall be included in the "Adoption/Custody Fee Disclosure Affidavit" as documented by the agency or attorney. This contract is for pre-placement adoptive and or custody home study services only. We understand that if post-placement home supervision services, or any other related services are requested or required, these are by separate contracts.We have been given the opportunity to ask all of our questions and we believe we understand the home study process and what we may expect. We feel that we are ready to begin a Louisiana adoption home study, or a Louisiana custody home study.Signed this ________day of _______________ 20___,___________________________________ ________________________________Applicant ApplicantAccepted by:_____________________________________Agency Director____________________ (Date)************************************************************************Responsible Party __________________________________________Check # ____________Amount $____________Date Received ______________ Rev. 02/16 ................
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