LETTERBOX INFORMATION FORM

When completing this form we would be grateful if you could bear in mind the following:-

§  Please read ‘Guidelines For Setting Up A Letterbox’.

§  Please complete the form as neatly as possible. The information you provide is all we have to set up and run the letterbox.

§  Where possible include postcodes and e-mail addresses.

§  Please indicate if couples are single sex.

§  Please make it clear if names could be either sex or if names are unusual, let us know the gender of each person.

§  Please complete the entire form, anything not applicable or unknown please indicate, we need as much information as possible.

§  Please attach a copy of the legal advice and the adoption support plan when returning this form.

THIS LETTERBOX IS BEING SET UP FOR:-

Child’s Birth Name………………………………………………………………………………………

1.  THE CHILD

Child’s adopted name
Date of birth
Date placed for adoption
Date of Adoption Order
Ethnic origin
Unitary Authority from which the child came
Does the child have a learning or physical disability?
If yes, please give details / Yes p No p

2.  ADOPTIVE PARENT(S)

Name of adoptive parent(s)
Address
Telephone number (Home)
Telephone number (Mobile)
E-mail address
If any other children in the adoptive home please give details / Name / Date of birth / Adopted or birth

3.  BIRTH MOTHER

Name
Address
Telephone number (Home)
Telephone number (Mobile)
E-mail address
Did birth mother meet adopter(s)? / Yes p No p
If they did meet, did it go well, if did not meet why?
Is the birth mother going to participate in letterbox? / Yes p No p

4.  BIRTH FATHER (Please complete even if not having Letterbox)

Name
Address
Telephone number (home)
Telephone number (mobile)
E-mail address
Did birth father meet the adopter(s)? / Yes p No p
If they did meet, did it go well if did not meet why?
Is birth father going to participate in letterbox? / Yes p No p

5.  MATERNAL GRANDPARENTS

(Please complete even if not having Letterbox)

Name
Address
Telephone number(s)
E-mail address
Are they going to participate in letterbox? / Yes p No p

6.  PATERNAL GRANDPARENTS

(Please complete even if not having Letterbox)

Name
Address
Telephone number(s)
E-mail address
Are they going to participate in letterbox? / Yes p No p

7.  SIBLINGS/HALF SIBLINGS

(Please complete even if not having Letterbox)

Birth name of sib/half sib
Date of birth
Current name
Address
Who do they live with and what is the relationship?
The child shares: / Birth mother p Birth father p
Both p
Are they going to be included in letterbox exchange? / Yes p No p
Birth name of sib/half sib
Date of birth
Current name
Address
Who do they live with and what is the relationship?
The child shares: / Birth mother p Birth father p
Both p
Are they going to be included in letterbox exchange? / Yes p No p
Birth name of sib/half sib
Date of birth
Current name
Address
Who do they live with and what is the relationship?
The child shares: / Birth mother p Birth father p
Both p
Are they going to be included in letterbox exchange? / Yes p No p
Birth name of sib/half sib
Date of birth
Current name
Address
Who do they live with and what is the relationship?
The child shares: / Birth mother p Birth father p
Both p
Are they going to be included in letterbox exchange? / Yes p No p

8.  OTHER SIGNIFICANT PEOPLE TO BE INCLUDED

Name
Relationship to the child
Address
Telephone number
Name
Relationship to the child
Address
Telephone number
Name
Relationship to the child
Address
Telephone number
Name
Relationship to the child
Address
Telephone number

9.  ADDITIONAL INFORMATION

Is there a court order for any contact? If yes please detail and enclose a copy of the order?
Are there any mental health issues within birth family that any visiting worker should be aware of?
Are there any drug or alcohol related issues within the birth family that any visiting worker should be aware of?
Are there any risk factors to do with violence that any visiting worker should be aware of?
Did birth parents contest the plan?
Are there any other issues you consider important?

10.  NON-OPERATIONAL LETTERBOX

If an exchange is not going to occur please explain. It is essential that we are aware and able to respond appropriately if contacted by people not originally include in these arrangements.
Are there circumstances in which it could be activated? Please give details.
Are all the parties aware the circumstances in which the non-operational letterbox could be activated and are they in agreement?

11.  WORKERS INVOLVED

Child’s social worker, name & phone number
Child’s homefinder, name and phone number
Link worker to adopter(s), name, address and telephone number
Other professional workers involved with the child and/or the placement

12.  PERSON COMPLETING FORM

Name
Office Address
Telephone Number
Mobile Number
E-mail address
Signature
Date forms completed

1

Adoption Procedures & Guidance

Section 10 – Appendix H

September 2011