loving houston adoption agency offering foster care and ... · 5 wife if more space is needed,...
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LovingHoustonAdoptionAgencyOfferingFosterCareandAdoptionServices
Questionnaire/Application
LastName FirstName(Husband) (Wife)Address: City: State: Zip: HomePhone: Husband:Cell: Work: Wife:Cell: Work: HusbandEmailcontact: WifeEmailcontact:
HUSBAND’SINFORMATIONAge DateofBirth Ethnicity Education Occupation PrimaryLanguage Otherlanguagesspoken Citizenship MarriageDate Divorce(s)?When?
WIFE’SINFORMATIONAge DateofBirth Ethnicity Education Occupation PrimaryLanguage Otherlanguagesspoken Citizenship MarriageDate Divorce(s)?When?
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CHILDREN:Name Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐No
Name Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐No
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PETS:Name Breed Indoor/Outdoor
DESCRIPTIONOFHOME:
1. Howlonghaveyouresidedatyourcurrentaddress? Years Months
2. Doyou(check):�Own�Rent/Lease�Mortgaged
3. Typeofneighborhood?(check)�Apartment�Rural�City�Town�Subdivisiona. #ofbedrooms #ofbathrooms
4. Whatwillbethesleepingarrangementsforthechild(children)youfoster/adopt?
5. Willthechild(children)besharingaroom?Ifyes,whichofyourchildrenwillbesharing
aroomwiththechild(children)?
6. Describeyourneighborhood,includingtheaverageincomelevel,ageofresidents,and
racialmakeup.
7. WhatIndependentSchoolDistrictareyouin?
8. Describeyourrelationshipwithyourneighbors.
CHURCHINFORMATION:
1. ChurchName:
2. Pastor’sName:
3. Isthehusbandamember(Check)�Yes�NoHowlong?
4. Ifthewifeamember(Check)�Yes�NoHowlong?
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RespondingtotheBiblicaladmonitiontopracticetrueandundefiledreligion(James1:27)LovingHoustonseekslike-mindedfamiliesincaringforthelittleones.Pleaseanswerthefollowingquestions.
HUSBANDIfmorespaceisneeded,pleaseattachanadditionalpagetothisform.ReadALLthequestionsfirstbeforeanswering.1.PleasewriteinyourownwordswhatagenuineChristianistoyou.2.DescribeyourconversionexperienceandexplainhowChristhaschangedyourlife.3.HowdoesyourChristianityaffectyourdailylife?(i.e.devotion,worship,interactionswithyourwork,family,spouse,etc)4.WhatdoesbeingaChristianhusbandandfathermeantoyou?5.Inyourunderstanding,whatisaChristianfamily?
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WIFEIfmorespaceisneeded,pleaseattachanadditionalpagetothisform.ReadALLthequestionsfirstbeforeanswering.1.PleasewriteinyourownwordswhatagenuineChristianistoyou.2.DescribeyourconversionexperienceandexplainhowChristhaschangedyourlife.3.HowdoesyourChristianityaffectyourdailylife?(i.e.devotion,worship,interactionswithyourwork,family,spouse,etc)4.WhatdoesbeingaChristianwifeandmothermeantoyou?5.Inyourunderstanding,whatisaChristianfamily?
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EMPLOYMENTINFORMATION:HusbandOccupation: CompanyName:
CompanyAddress:
City: Zip:
JobDescription(Pleasedescribejobdutiesandresponsibilities):Whatisyourdailyschedule?Doyouhaveanyflexibilityinyourschedule?Forexample,ifnecessary,canyouleaveworktotakeachildtodoctor/therapyappointments,schoolmeetings,biologicalfamily/siblingvisits?Howlonghaveyoubeenatcurrentjob? Years MonthsOnaseparatepieceofpaperpleaselistemploymentorbusinessforthelasttenyearsorsinceleavingschool.Pleaseincludethefollowing:a)Occupationb)Employerc)Datesd)Wage/SalaryWifeOccupation: CompanyName:
CompanyAddress:
City: Zip:
JobDescription(Pleasedescribejobdutiesandresponsibilities):Whatisyourdailyschedule?Doyouhaveanyflexibilityinyourschedule?Forexample,ifnecessary,canyouleaveworktotakeachildtodoctor/therapyappointments,schoolmeetings,biologicalfamily/siblingvisits?Howlonghaveyoubeenatcurrentjob? Years MonthsOnaseparatepieceofpaperpleaselistemploymentorbusinessforthelasttenyearsorsinceleavingschool.Pleaseincludethefollowing:a)Occupationb)Employerc)Datesd)Wage/Salary
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FINANCIALINFORMATION:MonthlyGrossIncome: Husband Wife
MonthlyNetIncome: Husband Wife
MonthlyExpenses Savings
Tithe Passbook
HousePayments Certificates
Utilities Stocks
Insurances U.S.Bonds
AutomobilePayment Other
Gasoline
Food
DebtPayments
ChildCare
Clothing
Medical
Pets
Legal(inc.attorneyfees,childsupport/alimony,etc.)
Misc./Other
TotalExpenses TotalSavings
LIFEINSURANCEINFORMATION:CompanyName:
ValueofPolicy: Husband Wife
Premium(monthlyorannually):Cost: Husband WifePleaseNote:OnlyincludecostifitisNOTreflectedinnetincome
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HEALTHINSURANCEINFORMATION:CompanyName:
TypeofCoverage(medical/dental):
Premium:MonthlyorAnnually(circleone)Amount:
Isthistakenoutinyourpaycheck?�YES�NOPleaseNote:OnlyincludethecostifitisNOTreflectedinnetincome.
RESIDENCES:Listthedatesandaddressesoftheplacesyouhaveresidedforthepast10yearsbeginningwiththecurrentaddress.
HusbandDates Address City State Zip
Wife
Dates Address City State Zip
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MEDICALINFORMATION-Husband(Pleaseuseadditionalpaperasneededforcompleteexplanation)
Handicaps Date DegreeofRecovery CurrentHealth
a)
b)
c)
ChronicConditions Date DegreeofRecovery CurrentHealth
a)
b)
c)
SeriousIllnesses Date DegreeofRecovery CurrentHealth
a)
b)
c)
Operations Date DegreeofRecovery CurrentHealth
a)
b)
c)
Abortion:Toyourknowledgehaveyoufatheredachildthatwassubsequentlyabortedormiscarried?Abortion: �Yes�NoMiscarried:�Yes�NoPleasebrieflyexplainanyemotionalsideeffectsandhowyouhaveresolvedorareattemptingtoresolvethisexperience?
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MEDICALINFORMATION-Wife(Pleaseuseadditionalpaperasneededforcompleteexplanation)
Handicaps Date DegreeofRecovery CurrentHealth
a)
b)
c)
ChronicConditions Date DegreeofRecovery CurrentHealth
a)
b)
c)
SeriousIllnesses Date DegreeofRecovery CurrentHealth
a)
b)
c)
Operations Date DegreeofRecovery CurrentHealth
a)
b)
c)
Abortion:Haveyoueverbeenpregnantwithachildthatwassubsequentlyabortedormiscarried?Abortion: �Yes�NoMiscarried:�Yes�NoPleasebrieflyexplainanyemotionalsideeffectsandhowyouhaveresolvedorareattemptingtoresolvethisexperience?
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FAMILYBACKGROUND:
Husband
NumberofBrothers: Adopted Step Biological
NumberofSisters: Adopted Step Biological
SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .
SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .
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HUSBAND’SPARENTSAreyourbiologicalparentsstillmarried?
�Yes,Howlong?
�No,Howlongweretheymarried?
Father Mother Name
Address
PlaceofBirth
Education
Occupation
Age
GeneralHealth
Deceased/Age
Causeofdeath
Frequency&TypeofContact
Step-Mother Step-Father Name
Address
PlaceofBirth
Education
Occupation
Age
GeneralHealth
Deceased/Age
Causeofdeath
Frequency&TypeofContact
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FAMILYBACKGROUND:
Wife
NumberofBrothers: Adopted Step Biological
NumberofSisters: Adopted Step Biological
SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .
SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .
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WIFE’SPARENTSAreyourbiologicalparentsstillmarried?
�Yes,Howlong?
�No,Howlongweretheymarried?
Father Mother Name
Address
PlaceofBirth
Education
Occupation
Age
GeneralHealth
Deceased/Age
Causeofdeath
Frequency&TypeofContact
Step-Mother Step-Father Name
Address
PlaceofBirth
Education
Occupation
Age
GeneralHealth
Deceased/Age
Causeofdeath
Frequency&TypeofContact
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PREVIOUSMARRIAGE(S):Husband Wife ToWhom DateofMarriage LocationofMarriage DateofTermination DivorcedorWidow(er)
Husband Wife ToWhom DateofMarriage LocationofMarriage DateofTermination DivorcedorWidow(er)
1. Doyouhavechildrenwithsomeoneotherthanyourcurrentspouse?a. Whataretheirnamesandages?
b. Wheredotheyreside?
2. Ifapplicable,whydidyougetmarriedtoyourpreviouspartner(s),andwhatledtothedivorce?Husband:Wife:
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ADDITIONALQUESTIONS:3. Doeseitherthehusbandorwifesmoke?�Husband�Wife
4. Doeseitherthehusbandorwifedrink?�Husband�WifeExplainhowmuchandonwhatoccasion:
5. Doeseitherthehusbandorwifeuseillegalorprescriptiondrugs?�Husband�Wife(Youmaybeaskedforarandomdrugtest)Pleasegivedetailsastowho,when,what,why?
6. Haveyoueverhadanaddictiontopornography? �Husband�WifeIfso,didyoureceivehelp,pleaseexplain.
7. Haseitherthehusbandorwifebeencharged(butnotconvicted)ofafelony?☐Husband☐WifeWho,What,When,Why?
8. Haseitherhusbandorwifebeenarrestedorincarcerated?�Husband�WifeWho,What,When,Why?
9. Hasanyoneinthehouseholdbeenseenbyamentalhealthprofessionalforcounseling/therapy?�Husband�Wife�Child:__________�OtherfulltimehouseholdmemberDatesofservice:NameandAddressofMentalHealthProfessional*:*Pleaseprovideastatementfromyourmentalhealthprofessionalthatincludesdatesofservice,theresolutionoftheissue,andanevaluationofthefamily’semotionalpreparednesstocareforachildwhohasexperiencedtrauma.
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ReferencesListthenamesandaddressesofFIVEreferencesasfollows;
1. Pastoral
a. Name:
b. Address:
c. City,State,Zip:
d. Phone:
2. Non-Relative(fromyourcommunity-example:schoolpersonnel,neighbor,etcetera)
a. Name:
b. Address:
c. City,State,Zip:
d. Phone:
3. Non-Relative
a. Name:
b. Address:
c. City,State,Zip:
d. Phone:
4. Non-Relative
a. Name:
b. Address:
c. City,State,Zip:
d. Phone:
5. Relative
a. Name:
b. Address:
c. City,State,Zip:
d. Phone:
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ChildPreferenceINDICATE YOUR PREFERENCES:Age(s) Gender Ethnicity Sibling (Group of)
☐0 to 3yrs. ■
☐4 to 8yrs. ■
☐ 9 to 12 yrs. ■
☐ 13 to 15 yrs. ■
☐ 16 to 18 yrs.
☐ Other .
☐ Male Only
☐ Female Only
☐ No Preference
☐Caucasian ■
☐Hispanic
☐ African/Amer ■
☐ Asian
☐ Native American ■
☐Other
☐ Bi-Racial
☐No Sibling Groups
☐2
☐ 3
☐ 4
☐ 5 or more
Twins: � Yes � NoAge Range of Siblings:
.
Listanyothersyouwouldconsiderthatarenotmentioned:
______________________________________________________________________________
______________________________________________________________________________
Comments:____________________________________________________________________
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A-----AcceptableWTD-WillingtoDiscussNA---NotAcceptable
LegalRiskLegalriskreferstoachildnotavailableforadoptionbecausehisparent’srightshavenotyetbeenterminatedorachildplacedinfostercarewiththeintentionofmovingtoanadoptiveplacement.
This preference list is a guide that helps you and the agency determine your strengths andassets inbecominga resource fora child-needingplacement. Someof theaboveconditionscannotbedetermineduntilachildbecomesolder.Thispreferencelistdoesnotguaranteethatachildplacedwithyourfamilywillnotdevelopsomeoftheconditionslistedonthisform.______________________________________ ____________________Foster/AdoptiveHusband Date______________________________________ ____________________Foster/AdoptiveWife Date
Child’sBirth&HealthHistory A WTD NA
Prematurity Apneaepisodes Historyofseizures Positivedrugscreendrugidentified Exposuretoalcoholduringpregnancy Mothersmokedduringpregnancy Mentalretardation Cerebralpalsy SpinaBifida Dietaryproblems Allergies HIVpositive
Correctable A WTD NA
Orthopediccondition Heartcondition Eyecondition Other
LegalRisk A WTD NA
LegalRisk
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We,_______________________________________________,declarethattheinformationonthisapplicationistrueandcorrect. WeunderstandthatanyerroneousinformationwouldbegroundsforLovingHoustonAdoptionAgencytodenyourapplicationordiscontinueanyfurtherprocessoftheplacementofachildintoourhome.
___________________________________________ _____________________
ProspectiveFather Date
__________________________________________ ______________________
ProspectiveMother Date
PleaseAttach:
! Apictureofhusbandandwife
! Apictureofyourchildren
! Picturesoftheoutsideofyourhome
Afamilypictureisacceptableaslongaseachfamilymemberisclearlydiscernable.