Life Focus Center

2211 So. Hacienda Blvd., Suite 103-C

Hacienda Heights, CA. 91745

626-330-7990

Dr. Elaine Kindle, Ph.D., LCSW, Board Certified Diplomat

Adoption Service Provider

BACKGROUND INFORMATION

ABOUT THE PROSPECTIVE ADOPTIVE PARENT(S)

Please complete this form and return it to Dr. Elaine Kindle prior to the Advisement. According to Family Code, your information and original signatures need to be in your ASP=s adoption case file. Thank you.

Identifying Information:

Name(s):______

Address:______

Street City Zip

County of Residence:______Home phone:______

Name:______

Work phone:______

Cell phone:______

Fax#:______

Emergency contact:______

______

Please include area codes for all numbers.

Name:______

Work phone:______

Cell phone:______

Fax#:______

Emergency contact:______

______

AP Background Information, cont.

ADOPTIVEPARENT:

Full Legal Name:______

Age:______DOB:______

Religion:______

SSN:______Driver=s License:______

Race/Ethnicity:______

No. of Previous Marriages:______

Highest Education:______

Profession:______

Employment:______

Gross Annual Income:______

ADOPTIVE PARENT:

Full Legal Name:______

Age:______DOB:______

Religion:______

SSN:______Driver=s License______

Race/Ethnicity:______

No. of Previous Marriages:______

Highest Education:______

Profession:______

Employment:______

Gross Annual Income:______

Please answer the following questions:

Please list the name & phone number of your attorney:______

______

What is the name of your birth parent:______

When were you matched?______

Do you have contact with the birth parent? Explain:______

______

AP Background Information, cont.

What is the date of your marriage or domestic partnership?______

Do you have any children? If so, please provide their names and birth dates. Are these children adopted, from this marriage, or from another marriage or relationship?

______

Do either of you have children from previous marriages or relationships who do not live in the home; do you have child support obligations for these children; and have you met any child support obligations? If yes, also please identify whose children they are, and their names and ages:

______

Have either of you had any children removed from your care due to child abuse or neglect? If yes, please explain who and why:

______

What are your child-care plans for the child you are planning to adopt?

______

Are there other children and/or adults residing in your home? If yes, please write the names and ages below and identify to whom they are related:

______

AP Background Information, cont.

Do either of you have any health conditions restricting your normal daily activities or reducing your normal life expectancy? If yes, please explain:

______

Are you taking any medications? For what purpose? Please include any psychotropic medications.

______

Do either of you have any convictions for crimes other than minor traffic violations? If yes, that person needs to answer the question below. You will need to include any information regarding any arrests or convictions, whether or not they were dismissed or expunged from your record. This information is released to SDSS and CDSS who shares this information with the birthparent(s). Your failure to report any such convictions or arrests may jeopardize this adoption:

______

Has your home study been completed? Yes/No

(Typically home studies are completed after placement in Independent Adoptions)

Do you anticipate any financial difficulty should a placement happen immediately? Yes/No

Do you understand the function of the Adoption Service Provider? Yes/No

Have you read the Fee Agreement and do you understand and agree to the charges and time lines? Yes/No

AP Background Information, cont.

What other information would you like to have regarding this adoption process?

______

Is there any other information about yourselves you would like to include?

______

Prospective Adoptive #1 Signature Prospective Adoptive #2 Signature

______

Date Date

07/06