Family Support Center of Florida, L



[pic]

Angela Quick, MPA Edna Lippi Brown, LMHC

Executive Director Director of Social Services

E-mail: angelaquick@

APPLICATION and AGREEMENT

NAME(S):

Home Telephone: Home Fax #:

Home Address:

Date & Place of Marriage:

Number of Children in home: Ages:

Please list any attorney or agency with whom you are currently working, including contact name, mailing address, and telephone number (for all adoptions): If none yet, please check here:

__________________________________________________________________________________________

Please let us know where you heard about our services: _____________________________________________

__________________________________________________________________________________________

Please read through the attached Menu of Services & Fees, then indicate all of the Adoption & Family Support Center service(s) you are applying for (please indicate with a checkmark or X):

A. _____ Child Placement Services C. _____ Non-placement Social Services

B. _____ Adoption Home Study D. _____ Custody Home Study

ADOPTIVE FAMILY PERSONAL INFORMATION

Full Name Applicant #1:

Cell phone: E-mail:

Date of Birth: Age: Sex:

Place of Birth: Race:

Height: Weight: Eyes: Hair:

Social Security # DL #

Name of Employer:

Employer Address:

Work Phone: Your title:

Education: Highest Grade Completed or Degree:

Facebook/Blog/Twitter addresses:

Full Name Applicant #2:

Cell Phone: E-mail:

Date of Birth: Age: Sex:

Place of Birth: Race:

Height: Weight: Eyes: Hair:

Social Security # DL #

Name of Employer:

Employer Address:

Phone: Your title:

Education: Highest Grade Completed or Degree:

Facebook/Blog/Twitter addresses:

LEGAL INFORMATION

NOTE: As the home study preparer, I must stress candor in answering all questions with regard to background clearances. You are required to disclose ALL possible abuse, criminal and family violence events that have occurred during your life, regardless of prosecution, disposition, or expungement. If you have any such events in your background, for purposes of the adoption process you will need to obtain certified copies of documents that show the outcome/disposition of the event.

Criminal Record

(If you have an arrest record from any local jurisdiction, state or country in which you have lived since you attained 18 years of age, you will be requested to obtain a copy of said arrest record and specific information regarding the outcome of the matter – regardless how minor.)

Have you ever been arrested? Applicant 1 [ ] Yes [ ] No Applicant 2 [ ] Yes [ ] No

Was the arrest in the State of Florida? [ ] Yes [ ] No [ ] Yes [ ] No

If not Florida, where? ________________ ________________

Abuse Record: (Note – your name may appear in a report if you called the report in, or someone else called in a report regarding your child at school, or other similar scenario.)

Have you ever been named in an abuse incident?

Applicant 1 [ ] Yes [ ] No Applicant 2 [ ] Yes [ ] No

Have you ever been treated for substance abuse?

Applicant 1 [ ] Yes [ ] No Applicant 2 [ ] Yes [ ] No

Have you ever been involved in a domestic violence situation?

Applicant 1 [ ] Yes [ ] No Applicant 2 [ ] Yes [ ] No

Were the above incidents In Florida?

Applicant 1 [ ] Yes [ ] No Applicant 2 [ ] Yes [ ] No

If not Florida, where? Applicant 1___________________ Applicant 2 ________________

Statement: If you answered yes to any question in this legal section, please provide a written description of the event, giving as much detail as possible, and including the specific information listed below (use a separate piece of paper per event):

Your name, Date of Event, City, State & County where event occurred

Detailed description of event

Date of disposition, the disposition and result

Rehabilitation - Time served, fines paid, etc.

Effect of the event on you, your family, your life

Your signature, printed name.

Document must be signed in the presence of a notary.

Legal Information on Other Household Members (Other than Applicants):

Other adults & relationship living in the home (parents, children over 18, college students):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Does anyone in your household have a record with Florida Department of Law Enforcement (FDLE), or an arrest or criminal record with any other state, or abuse registry record in Florida, another state or in another country?

[ ] Yes [ ] No

If yes, please list the name of the person, dates, place (city, county & stated) and outcome below.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

The person involved must complete a statement.

Statement: If you answered yes to any question in this legal section, the person it applies to must provide a written description of the event, giving as much detail as possible, and including the specific information listed below (use a separate piece of paper per event):

Name, Date of Event City, State & County where event occurred

Detailed description of event

Date of disposition, the disposition and result

Rehabilitation/Time served, fines paid, etc.

Effect of the event on you, your family, your life

Signature and printed name.

Document must be signed in the presence of a notary.

If domestic adoption or custody, please list addresses for past 5 years.

If International adoption, please list ALL addresses since age of 18. (Add additional sheets if needed)

APPLICANT 1:

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

If domestic adoption, please list addresses for past 5 years.

IfIinternational adoption, please list ALL addresses since age of 18. (Add additional sheets if needed)

APPLICANT 2:

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

___________________________________________________________ From: ________________

Street Address

___________________________________________________________ To: __________________

City, County, State, Country

FOR CUSTODY ONLY: Please list the names and ages of the children you are seeking custody for and the State in which they live:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

In whose custody are they now (circle one): Mine Other Parent Grandparent Other Relative

FOR ADOPTION ONLY – Adoption Budget __________________________

Please indicate your adoption preference (check all that apply):

_____ Domestic (U.S.) In Florida _____ or Interstate _____

_____ International First Country of Preference ________________________________________

Second Country of Preference _________________________________________

_____ Healthy ____ Special Needs: ID Special Needs__________________________________________

I would like to adopt: _____ One child _____ Two children More _______

If two children or more: _____ Siblings _____ No preference

We prefer to adopt a child or children in the following age group:

_____ An infant _____ 0 - 1 year _____ 1 - 2 years _____ 2 - 3 years _____ 3 - 5 years

If other than above, please state preference or circumstances:

Ethnicity of Child(ren) we would consider - write in all that apply (including mixed combinations):

(Example: Asian; Caucasian; Hispanic; Native American Indian; Eastern Indian; African American, Biracial)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Expectations for level of contact and relationship with the birthparent(s)- Please indicate level of openness and communication prior to the birth, as well as following the placement of the child into your family (for example; We are prepared for a partially-open adoption to include phone calls and/or a meeting prior to birth, attend delivery, and provide pictures and letter updates following birth). Please indicate expectations below:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

CHILD'S BACKGROUND INFORMATION

An infant or child may have the following health or development issues, disabilities, personality factors or pre-placement experiences. Be honest with yourself. If you already have a child, you must also give thought to how a child with any of these conditions would affect the child you have.

We all believe that we are compassionate, caring individuals whose hearts go out to a child with particular illnesses. But this exercise is about knowing yourselves and what fits your family and what does not fit.

Biological Family Background Information: The following conditions may be present in the birth families. Please consider the following and indicate your willingness to accept them as part of your child's heritage. This information is anecdotally reported by the birthparent(s), and not independently verified by the agency.

Situation/Condition Yes No Possibly Comments

|ADD or ADHD | | | | |

|Anxiety Disorders | | | | |

|Asthma | | | | |

|Bipolar Disorder/Manic depressive | | | | |

|Blindness or legal blindness | | | | |

|Cerebral Palsy | | | | |

|Club Foot | | | | |

|Congenital Heart Defect | | | | |

|Cystic Fibrosis | | | | |

|Deafness or Serious trouble hearing | | | | |

|Depression | | | | |

|Diabetes – Type 1 | | | | |

|Diabetes – Type II | | | | |

|Down’s Syndrome | | | | |

|Dyslexia | | | | |

|Hemophilia | | | | |

|Huntington's Disease | | | | |

|Learning Disability | | | | |

|Mental Retardation | | | | |

|Multiple Sclerosis | | | | |

|Muscular Dystrophy | | | | |

|Obsessive-Compulsive disorder | | | | |

|Schizophrenia | | | | |

|Seizures, Convulsions, Epilepsy | | | | |

|Sickle Cell Anemia | | | | |

|Sickle Cell Trait | | | | |

|Speech Problems | | | | |

|Substance Abuse | | | | |

|Tay-Sachs Disease | | | | |

Comments:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Birthparent Diagnoses and Circumstances: The following conditions may be present in the birth mother or birth father. Please consider the following and check all you are willing to accept. This information is anecdotally reported by the birthparent(s), and not independently verified by the agency.

Situation/Condition Birth Mom Birth Dad Comments

|ADD or ADHD | | | |

|Addiction history | | | |

|Anxiety Disorders | | | |

|Bipolar Disorder/Manic Depressive | | | |

|Depression | | | |

|Diabetes – Type 1 | | | |

|Diabetes – Type II | | | |

|Hepatitis | | | |

|HIV/AIDS | | | |

|Incarceration | | | |

|Learning Disability | | | |

|Obsessive-Compulsive disorder | | | |

|Prostitution | | | |

|Schizophrenia | | | |

|Seizures, Convulsions, Epilepsy | | | |

|Sickle Cell Anemia | | | |

|Sickle Cell Trait | | | |

|Prenatal Exposure specific to this pregnancy: | | |Indicate your level of comfort, or elaborate below: |

|Alcohol | | | |

|Amphetamines | | | |

|Barbiturates | | | |

|Cigarettes | | | |

|Cocaine/Crack | | | |

|Designer Drugs | | | |

|Heroin | | | |

|LSD | | | |

|Marijuana | | | |

|Methadone | | | |

|Methamphetamine | | | |

|Prescription Drugs | | | |

Comments:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

By making application with Adoption & Family Support Center, LLC (The Agency) and by my signature below:

I agree to work with The Agency to complete the services herein requested. I understand that I am required to disclose all criminal and abuse incidents to The Agency and will comply with the requirements thereof.

I agree to cooperate in all background searches to be conducted through the law enforcement and abuse registry agencies as requested by Adoption & Family Support Center, LLC in a timely manner.

I acknowledge receipt of the agency's Menu of Services & Fees. I understand that all fees charged by The Agency are non-refundable and must be paid in full prior to initiation of that service, and that fees are subject to change without notice.

I acknowledge that The Agency provides matching and placement services exclusively to Prospective Adoptive Parents who commit to providing the level of contact they have agreed upon with their Birthparent(s).

I further authorize The Agency to send me the documents necessary to complete the next step in the services I am requesting.

Date: _______________ ___________________________________

Applicant 1 Signature

___________________________________

Applicant 1 Printed Name

Date: _______________ ___________________________________ Applicant 2 Signature

___________________________________

Applicant 2 Printed Name

-----------------------

Adoption & Family Support Center, LLC

A Licensed Child Placing Agency

709 Hills Blvd, Port Orange, Fl. 32127 (386) 760-5804 Fax (386) 322-3349

Toll Free (866) 221-6562

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download