Public Adoption Portfolio Acknowledgement



Public Adoption Portfolio AcknowledgementUse of Form: Use of this form is voluntary, but by signing the form, the adoptive parent(s) acknowledge they have received and reviewed all the information that has been checked in the accompanying portfolio. A signed copy of this form must be placed in the child’s adoptive case file, and a copy must be provided to the adoptive parent(s). Personal information you provide may be used for secondary purposes [Privacy law, s. 15.04(1)(m), Wisconsin Statutes.]Instructions: The public adoption professional will identify what items were shared with the adoptive parent(s) by checking the box. If any additional materials were shared, they can be added in the additional documents/reports row. Once the form has been completed, the adoptive parent(s) should sign the form and return to the public adoption professional. It will then be uploaded into eWiSACWIS.Section 1: Child & Parent InformationChild Full Name FORMTEXT ?????Child Date of Birth (mm/dd/yyyy) FORMTEXT ?????Adoptive Parent 1 Full Name FORMTEXT ?????Adoptive Parent 2 Full Name FORMTEXT ?????Section 2: Education InformationI. School Information FORMCHECKBOX Not Applicable FORMCHECKBOX School Reports (e.g., Report Cards) FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????II. Special Education Information FORMCHECKBOX Not Applicable FORMCHECKBOX Current Individualized Education Plan (IEP)Date of Last IEP Meeting: FORMTEXT ????? FORMCHECKBOX Behavior Intervention Plan (BIP)Date of Last BIP Meeting: FORMTEXT ????? FORMCHECKBOX Evaluation ReportsName of Reports: FORMTEXT ????? FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????Section 3: Health InformationIII. Medical Information FORMCHECKBOX Not Applicable FORMCHECKBOX Birth Records FORMCHECKBOX Medical Records FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????IV. Mental Health Information FORMCHECKBOX Not Applicable FORMCHECKBOX Treatment Plans FORMCHECKBOX Psychological Records/EvaluationsName of Evaluations: FORMTEXT ????? FORMCHECKBOX Psychiatric Records/EvaluationsName of Evaluations: FORMTEXT ????? FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????Section 4: Birth Family History FORMCHECKBOX Medical/Genetic Form FORMCHECKBOX Pregnancy/Delivery Form FORMCHECKBOX Social History FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????Section 5: Legal Documents FORMCHECKBOX Adoptive Family Placement Agreement (if applicable) FORMCHECKBOX Additional Documents/Reports: FORMTEXT ?????Section 6: Adoption Assistance InformationPublication NamePublication Number FORMCHECKBOX Not Applicable FORMCHECKBOX Adoption Assistance: General InformationDCF-P-PFS0105 FORMCHECKBOX Adoption Assistance Changes in Adoptive Family CircumstancesDCF-P-PFS4113 FORMCHECKBOX Adoption Assistance Contact Information CardDCF-P-PFS4064 FORMCHECKBOX Adoption of Children with an Adoption Assistance Agreement One Time Expense ReimbursementDCF-F-CFS0459 FORMCHECKBOX Reimbursable Expenses when Adopting Children with Special Care NeedsDCF-P-PFS0747 FORMCHECKBOX Additional Documents: FORMTEXT ?????Section 7: Medical Assistance InformationPublication NamePublication Number FORMCHECKBOX Not Applicable FORMCHECKBOX Adoption and Medical Assistance: Frequently Asked Questions (FAQ)Only provided when a child has an adoption assistance agreement either at-risk ($0) or with a subsidy.DCF-P-5595 FORMCHECKBOX Additional Documents: FORMTEXT ?????Section 8: ResourcesPublication NamePublication Number or Website FORMCHECKBOX Wisconsin Family Connections Center One Page Info FORMCHECKBOX Adoption Search Program Information SheetDCF-P-PFS0005A FORMCHECKBOX Additional Documents: FORMTEXT ?????Section 9: AcknowledgementBy signing below, I acknowledge that I have reviewed and received all of the items checked on this form for the child identified. FORMTEXT ????? FORMTEXT ?????Adoptive Parent 1 SignatureDate SignedAdoptive Parent 2 SignatureDate Signed ................
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