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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