Open Arms Adoption Services, Inc

OPEN ARMS ADOPTION SERVICES, INC.

A Non-Profit Louisiana Licensed Child Placing Adoption Agency

7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105

Telephone: 318-798-7664 Fax: 318-861-1710

D. Missy Everson, LCSW, DCSW, Executive Director

APPLICATION PACKET INSTRUCTIONS

Prior to printing out, please check to make sure the pages realigned correctly.

The attached Application Packet contains the following:

Application (3 Pages)

Explanation of Background Checks (1 Page)

Required Documents List (1 Page)

Medical Release/Physician’s form(2 Pages)

Child Medical (if you have a child in the home – 2Page)

References Release/Contact Information(1 Page)(One relative from each side of the family, and 4 unrelated persons who know both of you, plus at least one current employer/supervisor)

Duty To Disclose Form (1 Page)

Contract(2 Pages)

1 - Please complete the Application, Reference Release/Contact Information, and Contract;sign alland return to us with your home study fee (listed in contract) made payable to Open Arms Adoption Services, Inc.

2 - Arrange your doctors’ appointments, complete and sign the tops of your medical forms, and bring this form to your physician’s appointment to be completed and signed by the doctor or NP.

3 - Gather and make a copy of each of the documents on the Required Documents List.

4 – Hold everything from 2 and 3 until the first meeting with your social worker. We do not want to have any of these lost in the mail.

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Once we receive your Application, Contract, Fee, and References Release, we will contact you to arrange the home visit and interview appointments. We will then send you by e-mail the forms to complete for each interview/visit. Please feel free to email a reminder to me if you do not receive once the appointment times are arranged.

At any point please let us know if you have any questions. We look forward to working with you during your adoption home study, and beyond. You are on your way!

APPLICATION FOR HOME STUDY SERVICES

Please write very legibly

Husband Wife

Full Legal Names: *** *

Called: *** *

Date of Birth/Age: *** *

Place of Birth: *** *

Height and Weight: *** *

Hair/Eye/Complexion: *** *

Social Security #: *** *

Driver’s License # / State: *** *

Date of Marriage/Years Married: *

Place of Marriage/Parish/County: *

Previous Marriages: *** *

Citizenship: *** *

Ancestry/Ethnicity *** *

Religion: *** *

Education/Degree in: *** *

College/University: *** *

Location/City/State: *** *

Occupation: *** *

Current Employer: *** *

Location: *** *

If military, rank *** *

Years of service: *** *

Page 2 – Application

Home Address and Parish: *

Home Phone: *

Cell Phones: *** *

E-Mails: *** *

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Children in Home:

Name and DOB: *

Name and DOB: *

Name and DOB: *

Children Out of the Home, Including Adult Children:

Name and DOB: *

Name and DOB: *

Name and DOB: *

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Previous Adoption Information

Have you applied to adopt anywhere else currently or in the past? If so, please give details (where, when, outcome, etc.).

Have you ever been turned down by an agency or attorney for any reason other than too many families on the waiting list? If so, please give details.

Please give any additional information and discuss your prior adoption experience.

Page 3 – Application

Previous Address:

The federal Adam Walsh Act requires a list of every residence since age 18 on both applicants (city, parish/county, state, and in what years). Child abuse background checks will be conducted in all the states in which you have resided since age 18. Please list below or on separate sheet, or sign if applicable:

Husband: I have never lived or worked outside of Louisiana since age 18 Sign ______

Wife: I have never lived or worked outside of Louisiana since age 18 Sign ______

PLEASE PRINT LEGIBLY

Name when lived there City County/Parish State Year/Years

We have completed this application truthfully and we feel ready to start the adoption process.

Signed,

______

Husband Date WifeDate

PERSONAL DISCLOSURE AGREEMENT

And

DUTY TO DISCLOSE

I (We) understand that the home study process entails a duty to disclose and discuss all instances of substance abuse, mental illness, domestic violence, previous marriages, child neglect or abuse, and criminal arrest, charges, or convictions. I (We) understand that these disclosures do not necessarily disqualify me (us) as an adoptive parent(s), but not disclosing and having such information found out by the social worker, the Court, the Citizenship and Immigration Services, or the Department of Children and Family Services, may disqualify me (us) as an adoptive parent(s), may result in the denial of the placement of a child, or the denial of the immigration of a child, or the denial of the finalization of an adoption, or the removal of a potential adoptive child, or the denial of custody rights.

I (We) further understand that I (we) have a duty to disclose all such information, and understand that if I(we) have not disclosed such information, I (we) will not be entitled to a refund of any money already paid for any adoption or custody services.

I (We) also understand that even if I (we) have disclosed such information, that if I (we) choose to complete the home study process and submit the completed approved study to the Court, another agency, attorney, or USCIS, that this agency cannot guarantee the decisions of the other agency, attorney or any Court, or the USCIS, and therefore, any fees paid to date will not be returned regardless of outcome.

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I (We) have read, understood, been given the opportunity to ask questions, and have agreed to disclose all the above information. This disclosure is being signed with full knowledge that there is a penalty of perjury in knowingly withholding information or giving false information in an adoption or custody home study.

Signed,

______

Parent Applicant Date

______

Parent Applicant Date

Explanation of Background Checks

There are three different background checks that we will need for your home study. These are for each parent adopting as well as each household member who is 17 or older.

1 – StatePolice Criminal Check– These are conducted through biometrics with the Sheriff’s office in the parish in which you reside. The agency must make an appointment with them before you can have this done. Once we begin the home study, we will arrange the appointment. The results will be sent directly to a site that we are authorized to access about 3-5 days later. The cost generally runs about $45 per person paid to your parish’s Sheriff’s office. Please retain your receipt.

2 – Child Abuse Registry Check – These are conducted by the LA Dept. of Children and Family Services through us after you have completed the release during the home study process. There is no charge for the initial registry check, but we charge a $5.00 service fee per family for each subsequent annual check needed. It takes about 2-4 weeks for them to return the results to us. If you have lived in other states, some states do charge for this, and we will let you know what the fee is, so that you can reimburse the agency. These child abuse checks take various times to conduct so please be advised that we cannot issue the study until all are returned.

3 –FBI – You will arrange these yourself by going to . Follow the prompts, arrange an account for each of you as directed, and arrange a date for biometrics at a location nearest to you. You will be notified when the results are ready for you to access, usually 24-72 hours after submission. Please read their FAQs, as results are only available for a few days. Print out several copies of the results once you access them. We need at least one to three copies, and you should keep a copy as well. Cost is $50 per person to Fieldprint. Do not complete your FBI until you have the home visit appointments arranged, as they expire annually.

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If you should have a conviction on your record, then ask the Clerk of Court from the Court in which the hearing/trial was held for a copy of the Disposition of the Case and or the Court Minutes. This must be included in the home study. There may or may not be a charge for the copy you request from the Clerk of Court. And some Courts do generic minutes, so you will have to get further specific paperwork from the court to detail the Disposition. Louisiana Criminal Code Article 894 regarding expungement still allows the arrest to come up in your record and then lists the expungement, so the court minutes are still needed.

ADOPTION HOME STUDY

REQUIRED DOCUMENTS LIST

1 – Certified or copies of certified Birth Certificates on each parent and child in the household

2 – Certified or a copy of a certified filed copy of your Marriage Certificatewith filing date and/or book and page number, or other identifying file number

3 – If married previously, a copy of a certified copy of the Death Certificate or the Divorce Judgment is required.

4 – Copies of your Social Security cards - applicant(s) only

5 – Copies of your Driver’s Licenses– make sure it is not expired (copy also the back if there is a renewal sticker), and that the address is your current addressunless you travel with a military ID

6 – If working toward an international placement, color copies of your Passports

7 - The last three years of the front and back of your IRS 1040 tax forms; just the 1040, not the other forms, unless self-employed, then copy the Schedule C or E also

8 – Insurance verification for: (please do not copy entire policies, only a facesheet or appropriate page with info needed)

Home: must have your name, address, insurance company name, policy number, and the expiration date.

Health: must have your name, insurance company name, policy number, and verification that an adopted child will be covered/how/when.

Auto: must have your name, insurance company name, policy number, car description, and expiration date.

Life: must have the coverage amount and type (whole, term, etc.) of insurance, and the beneficiary shown.

Disability: must have your name, insurance company name, policy number, and a brief description. This could be a copy of the appropriate page from your insurance handbook, or a letter from your insurance administrator.

9 – Verification that a retirement plan is in place

10 - If you have pets, a veterinary statement (shot record, detailed bill, etc.) that all the shots are current on each animal

11 – Copies of your wills are not necessary, but I must make the statement regarding guardianship, that the guardianship plan will be reflected in your wills after placement. It is highly recommended that you make arrangements for your wills if you do not already have them in place.

OPEN ARMS ADOPTION SERVICES, INC.

A Non-Profit Louisiana Licensed Child Placing Adoption Agency

7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105

Telephone: 318-798-7664 Fax: 318-861-1710

D. Missy Everson, LCSW, DCSW, Executive Director

ADOPTIVE PARENT'S MEDICAL REPORT

NAME:______DOB: ______

Age______SS#______

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Dear Doctor______,

You are hereby authorized to complete this form on me, and to give Open Arms Adoption Services, Inc. any additional information as requested concerning my health and infertility status.

Signed, ______

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Date of examination:______

Height:______Weight: ______lbs. Blood Pressure:_____/____

* Is this patient free of all communicable diseases? ______If not, please detail. ______

* Has the patient been treated for any acute illnesses or conditions within the last six months? ______If so, please describe, including medication, and if resolved. ______

______

*Is the patient being treated for any chronic illnesses or conditions? ______If so, please give the DX, PX, TX, and if on medication, please list name, dose, reason, and expected duration. ______

______

*Has the patient received a DX and TX for infertility? ______If so, please describe current status. ______

*Is it your opinion that this patient is in good physical, mental and emotional health and capable of parenting an adoptive child? ______If not, please comment. ______

______

*Do you recommend adoption? ______

Signed, ______M.D.

Print Name______

Or Stamp

Address: ______

OPEN ARMS ADOPTION SERVICES, INC.

A Non-Profit Louisiana Licensed Child Placing Adoption Agency

7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105

Telephone: 318-798-7664 Fax: 318-861-1710

D. Missy Everson, LCSW, DCSW, Executive Director

ADOPTIVE PARENT'S MEDICAL REPORT

NAME:______DOB: ______

Age______SS#______

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Dear Doctor______,

You are hereby authorized to complete this form on me, and to give Open Arms Adoption Services, Inc. any additional information as requested concerning my health and infertility status.

Signed, ______

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Date of examination:______

Height:______Weight: ______lbs. Blood Pressure:_____/____

* Is this patient free of all communicable diseases? ______If not, please detail. ______

* Has the patient been treated for any acute illnesses or conditions within the last six months? ______If so, please describe, including medication, and if resolved. ______

______

*Is the patient being treated for any chronic illnesses or conditions? ______If so, please give the DX, PX, TX, and if on medication, please list name, dose, reason, and expected duration. ______

______

*Has the patient received a DX and TX for infertility? ______If so, please describe current status. ______

*Is it your opinion that this patient is in good physical, mental and emotional health and capable of parenting an adoptive child? ______If not, please comment. ______

______

*Do you recommend adoption? ______

Signed, ______M.D.

Print Name______

Or Stamp

Address: ______

OPEN ARMS ADOPTION SERVICES, INC.

A Non-Profit Louisiana Licensed Child Placing Adoption Agency

7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105

Telephone: 318-798-7664 Fax: 318-861-1710

D. Missy Everson, LCSW, DCSW, Executive Director

CHILD’S MEDICAL REPORT

Family Name: ______Today's Date: ______

Child's Name: ______DOB: ______

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Dear Doctor ______:

You are hereby authorized to complete this form on my child and to give Open Arms Adoption Services any additional information as requested concerning his/her physical or medical condition.

Signed, ______Parent

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Date of examination: ______

Height/length: ______Weight: ______Temp.: ______

1. Are all immunizations on schedule? Yes No (Please attach a copy of the immunization record).

Allergic reactions? (Please explain). ______

2. Is this child free of all communicable diseases? Yes No

If "No", what does this child have and what is the treatment?

______

3. Has this child been treated for any acute conditions within the last six months? Yes No

If "Yes", please give Dx, Tx, medications, if resolved, etc.

______

______

Child Medical Form – Page 2

4. Is the child being treated or tested for any chronic conditions? Yes No

If "Yes", please give Dx, Px, Tx, medications, recommendations, etc.

______

5. Does this child have any medical allergies? Yes No

If "Yes" please list: ______

6. Is this child developing within normal limits? Yes No

Comments? ______

7. Do you consider this child to be in good physical and emotional health? Yes No

Comments? ______

8. Is it your opinion that this child is receiving good medical care? Yes No

Comments? ______

9. Is it your opinion that this child is receiving proper nurturing and parenting? Yes No

Comments? ______

10. Any health recommendations or additional comments? Yes No

Comments? ______

Signed, ______M.D.

Print Name ______

Address ______

Please return to the above address or give to the parent to return to us. Thank you.

REFERENCE RELEASE FORM

ADOPTION HOME STUDY

I(we) request that the following persons be contacted as references regarding my(our) application to adopt a child.

I(we) understand that the content of these responses will be confidential.

SIGN:******Husband: ______Date: ______

******Wife: ______Date: ______

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PERSONAL (6): PLEASE PRINT LEGIBLY

Name: ______(Relative of husband)

Address: ______ZIP: ______

Email: ______

Name: ______(Relative of wife)

Address: ______ZIP: ______

Email: ______

Name: ______(Unrelated to either)

Address: ______ZIP:______

Email: ______

Name: ______(Unrelated to either)

Address: ______ZIP: ______

Email: ______

Name: ______(Unrelated to either)

Address: ______ZIP: ______

Email: ______

Name: ______(Unrelated or use pastor if desired)

Address: ______ZIP: ______

Email: ______

EMPLOYER of HUSBAND: (Please do not put your HR Dept.)

Name of Supervisor: ______Title: ______

Business Name: ______

Mailing Address: ______ZIP: ______

EMPLOYER OF WIFE: (Please do not put your HR Dept.)

Name of Supervisor: ______Title: ______

Business Name: ______

Mailing Address: ______ZIP: ______

Grown Child 1 (if applicable):

Name: ______Child of: ______

Address: ______ZIP: ______

Email: ______

Grown Child 2 (if applicable):

Name: ______Child of: ______

Address: ______ZIP: ______

Email: ______

OPEN ARMS ADOPTION SERVICES, INC.

A Non-Profit Louisiana Licensed Child Placing Adoption Agency

7330 Fern Avenue, Suite 204, Shreveport, Louisiana, USA 71105

Telephone: 318-798-7664 Fax: 318-861-1710

D. Missy Everson, LCSW, DCSW, Executive Director

ADOPTION/CUSTODY HOME STUDY CONTRACT

We request that a pre-placement adoptive/foster care/custody home study be conducted by Open Arms Adoption Services, Inc., A Louisiana Licensed Non-Profit Child Placement Adoption Agency, in fulfillment of the requirements of the Louisiana Children's Code, Section 11, Chapter 2, Articles 1171-1174, and the Louisiana Administrative Code according to the 2010 Legislative Act 64, Title 67, Part V, Subpart 8, Chapter 73, Article 7315.

The Home Study shall include the following:

1 – A minimum of two home visits, plus an additional home or office visit are required, including separate face-to-face interviews with each member of the household. All adult members of the household must be present during the home visits. Children may be interviewed in the home or office.

2 –New FBI and State Police criminal background checks, and child abuse clearance checks for each applicant and each adult member of the household are required.Child Abuse checks must be requested and received from each state any adult in the household has resided in since age 18, as required by the federal Adam Walsh Act.

3 - Evidence of a physical examination performed within six months of the study, verifying that each person in the household suffers no communicable disease, acute or chronic condition, illness or disability that would interfere with the family's ability to parent a child.Forms are provided by the agency; applicants may go to their own physician.