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Home
About
Legal Services
Divorce
Custody
Paternity
Auto Accidents
Slip & Fall
Contact
Let’s Talk
Menu
Home
About
Legal Services
Divorce
Custody
Paternity
Auto Accidents
Slip & Fall
Contact
Let’s Talk
CLIENT QUESTIONNAIRE
Adoption Intake Form
Date
MM slash DD slash YYYY
HOW WERE YOU REFERRED TO US?
Name: Last, First, Middle, (Maiden)
Last Name
First Name
Middle
(Maiden)
DOB
MM slash DD slash YYYY
Sex
Male
Female
Driver’s License Number
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Address
Street Address
City
State
Zip Code
County
Home Phone
Work Phone
E-Mail Address
Cell Phone
Place of Employment
Job Title
Address of Employment
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Annual Salary
Spouse Information
Spouse’s Name: Last, First, Middle, (Maiden)
Last Name
First Name
Middle Name
(Maiden)
DOB
MM slash DD slash YYYY
Address(if different from yours)
Street Address
City
State
Zip Code
County
Employer
Work Phone
Email Address
Cell Phone
Home Phone
PERSON FINANCIALLY RESPONSIBLE
Name: Last, First, Middle
Last Name
First Name
Middle Name
DOB
MM slash DD slash YYYY
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Driver’s License #
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
EMERGENCY CONTACT INFORMATION
Name: Last, First, Middle
Last Name
First Name
Middle Name
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone
Work Phone
Cell Phone
What legal action(s) were you involved in previously, if any?
Have you or family member been involved in any type of accident in the last 2 years?
Yes
No
If yes, list accident(s).
Have you or a family member ever suffered any serious injuries after taking a prescription or non-prescription drug?
Yes
No
If yes, describe injury or injuries.
Do you currently have a will?
Yes
No
Have you been denied Social Security benefits?
Yes
No
Have you been denied Veterans benefits?
Yes
No
Do you have need of legal assistance for any other matter?
Yes
No
If yes, explain.
Purpose of visit today
FATHER OF CHILD(REN)
Name: Last, First, Middle
Last Name
First Name
Middle Name
DOB
MM slash DD slash YYYY
Address
Street Address
City
State
ZIP Code
County
How long in county?
Please specify how many years & months
U.S. Citizen?
Yes
No
Driver’s License #
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Place of Birth
City
County
State
Employer
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Gross Monthly Pay
Paid: Check one
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Does your employer offer benefits for adoption?
Yes
No
If yes, how much does your employer offer you?
Home Phone
Work Phone
Mobile Phone
E-mail Address
CHILD(REN) TO BE ADOPTED
Add child(ren)
Full Name (First Middle, Last)
Date of Birth
Place of Birth (City, County, State)
Add
Remove
OTHER:
Do both biological parents agree to adoption?
Yes
No
Are you related to either parent?
Yes
No
If yes, which parent?
Mother
Father
Were the parents of the child(ren) ever married?
Yes
No
If Yes, Date and State of Marriage
Are the parents of the child(ren) divorced?
Yes
No
If Yes, Date and State of Divorce
Are either of the parents currently incarcerated?
Yes
No
If so, please provide details
Can you provide copy of birth certificate(s)?
Yes
No
Where do(es) the child(ren) reside?
With whom?
Child(ren) have resided with said party since
MM slash DD slash YYYY
Who presently provides health insurance for the child(ren)?
Mother
Father
Monthly Fee for insurance
Monthly court ordered child support
Arrearage
Have you been involved with any Family Law proceeding with any Court or the Attorney General’s office?
Yes
No
If yes, please explain fully when, where, and why.
Have you ever filed Bankruptcy?
Yes
No
If yes, please explain where, when, and the disposition.
Is Child Protective Services involved or have they ever been involved with this matter?
Yes
No
If yes, please explain when, where and why.
Please select and explain below if you or any one associated with this case been the subject of a:
Protective Order
Restraining Order
Child Protective Services Investigation
Mental Health Professional Treatment
Questionable Paternity Status
Substance Abuse Treatment
Welfare of Aid to Families with Dependent Children
Termination of Parental Rights
Prenuptial Agreement or Partitioning Agreement
Personal Injury Lawsuits. If so please explain:
Please explain the checked selection(s) below:
