Division of Youth and Family Services

Division of Youth and Family Services

CP&P Form 26-53c

(rev. 12/2006)

State of New Jersey

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Child Protection and Permanency

INDIVIDUAL AND FAMILY ASSESSMENT OUTLINE-ADOPTION

Child Summary Outline-Part A
Identifying Information

Case ID#:

Person ID:

Name:

Date of Birth:

Place of Birth:

Race:

Sex:

Ethnicity:

Religion:

Social Security Number:

Legal Status (appropriate legal status and enter effective date)

Legally Free: Date of GSPorDate of DAG Clearance

Pending DAG Clearance

Prior to GSP: Date Pre-Adopt Permission Given

GSP on AppealNext Court date

Current Living Arrangement of Child

Type of Placement

Living with

Address

Has child previously had an adoption disruption?Yes No

Is child currently residing with any siblings?Yes No

If so, please list siblings

Does child need to be placed with siblings? Yes No

If so, which siblings

CP&P 26-53c

(rev. 12/2006)

Birth Parents

Mother’s Name

Date of BirthPlace of Birth SS #

Race

ReligionEducation Level

Marital Status:Married Civil Union Partnership Widowed Divorced Dissolution of Civil Union Single

Date of Marriage/Civil Union Partnership

To whom

Date of Death (if applicable)

Birth/Putative Father’s Name

Date of BirthPlace of Birth SS #

Race

ReligionEducation Level

Marital Status:Married Civil Union Partnership Widowed Divorced Dissolution of Civil Union Single

Date of Marriage/Civil Union Partnership

To whom

Date of Death (if applicable)

Legal Father’s Name

Date of BirthPlace of Birth SS #

Race

ReligionEducation Level

Marital Status:Married Civil Union Partnership Widowed Divorced Dissolution of Civil UnionSingle

Date of Marriage/Civil Union Partnership

To whom

Date of Death (if applicable)

CP&P 26-53c

(rev. 12/2006)

Siblings

NameRelationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living ArrangementSS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Signature of Permanency/Adoption WorkerDate

Signature of SupervisorDate

CP&P 26-53c

(rev. 12/2006)

Siblings (Attach this page and provide the information for each additional sibling)

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

Name Relationship to the Child:

SexF M Race Date of Birth Place of Birth:

Living Arrangement SS #

Address

NameRelationship to the Child:

SexF M RaceDate of Birth Place of Birth:

Living ArrangementSS #

Address

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