Bethany Christian Services

BETHANY CHRISTIAN SERVICES

INTERCOUNTRY ADOPTION

OUR FAMILY CARE TEAM

Bethany Office:
Office/Branch Name:
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Our worker’s name:
Telephone number: / Email address:
Contact for needs related to:
Post-Adoption Specialist’s name:
Telephone number: / Email address:
Contact for needs related to:
Other contact name:
Telephone number: / Email address:
Contact for needs related to:
Other Homestudy or Placing Agency (if applicable):
Name of Agency:
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Our worker’s name:
Telephone number: / Email address:
Health Care:
Pediatrician’s Name:
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Web Address:
Insurance Accepted:
Dentist’s Name:
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Web Address:
Insurance Accepted:
Development:
Name of Early Intervention Services Agency (children 0-3):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Our worker’s name:
Telephone number: / Email and/or Web Site:
Developmental Specialist’s Name (OT, Speech, Hearing, Vision, etc.):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Email and/or Web Site:
Rates/Insurance: / Details of Practice:
Developmental Specialist’s Name (OT, Speech, Hearing, Vision, etc.):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Email and/or Web Site:
Rates/Insurance: / Details of Practice:
Language:
Informal Translator/Interpreter:
Address: / City/State/Zip:
Telephone number: / Emergency number: / Fax:
Email Address:
Formal Translator/Interpreter:
Address: / City/State/Zip:
Telephone number: / Emergency number: / Fax:
Email Address:
Mental Health:
Therapist’s Name (experience with adoption and needs of children who have experienced trauma):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Email and/or Web Site:
Rates/Insurance: / Details of Practice:
Therapist’s Name (experience with adoption and needs of children who have experienced trauma):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Email and/or Web Site:
Rates/Insurance: / Details of Practice:
Therapist’s Name (experience in treating depression):
Address: / City/State/Zip:
Main office number: / Emergency number: / Fax:
Practice/Clinic Name: / Email and/or Web Site:
Rates/Insurance: / Details of Practice:
Education:
School:
Address: / City/State/Zip:
Main office number: / Fax:
District: / District Website:
Contact Information for School or District Special Education/Exceptional Children’s Services:
Contact Information for School or District Psychological Services:
Teacher(s) names (once known):
Child Care Provider:
Name of Provider:
Address: / City/State/Zip:
Contact Name: / Phone: / Email:
Website: / Hours: / Fees:
Notes:
Babysitter:
Name of Provider:
Address: / City/State/Zip:
Referred by: / Phone: / Email:
Notes:
Name of Provider:
Address: / City/State/Zip:
Referred by: / Phone:
Notes:
Name of Provider:
Address: / City/State/Zip:
Referred by: / Phone:
Notes:
Support or Peer Groups:
Name of Group for Parents:
Address: / City/State/Zip:
Contact Name: / Phone: / Email:
Meeting Location: / Meeting Time:
Details (fees, childcare provided, etc.):
Name of Group for Parents:
Address: / City/State/Zip:
Contact Name: / Phone: / Email:
Meeting Location: / Meeting Time:
Details (fees, childcare provided, etc.):
Name of Group for Children:
Address: / City/State/Zip:
Contact Name: / Phone: / Email:
Meeting Location: / Meeting Time:
Details (fees, childcare provided, etc.):
Name of Group for Children:
Address: / City/State/Zip:
Contact Name: / Phone: / Email:
Meeting Location: / Meeting Time:
Details (fees, childcare provided, etc.):
Respite Care Providers:
Name:
Address: / City/State/Zip:
Main Phone: / Emergency Phone: / Email:
Availability (hours, weekend, week, etc.):
Criminal background check on file with Bethany? (for overnight care prior to finalization):
Name:
Address: / City/State/Zip:
Main Phone: / Emergency Phone: / Email:
Availability (hours, weekend, week, etc.):
Criminal background check on file with Bethany? (for overnight care prior to finalization):
Name:
Address: / City/State/Zip:
Main Phone: / Emergency Phone: / Email:
Availability (hours, weekend, week, etc.):
Criminal background check on file with Bethany? (for overnight care prior to finalization):
Family Mentors:
Family’s Name:
Address: / City/State/Zip:
Phone: / Email:
Adoption Details (age & gender of child, country, etc.):
Family’s Name:
Address: / City/State/Zip:
Phone: / Email:
Adoption Details (age & gender of child, country, etc.):
Other Post-Adoption Resources/Supports:
Name:
Address: / City/State/Zip:
Phone: / Email/Website:
Type of Service/Support:
Name:
Address: / City/State/Zip:
Phone: / Email/Website:
Type of Service/Support:

Store this resource in a place where you can quickly find it for reference

or to provide copies to substitute caregivers

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