FOR THE COUNTY OF County.
In the Matter of the Adoption Petition of:
Child's name. / )
)
)
)
) / No. Adoption petition number. If none, leave blank.
Post Placement Report
D.O.B. Child's Date of Birth.
By Petitioner:Adoptive Family's name.
Adoptive Family's street address.
Adoptive Family's city, state and zip code.
Petitioner’s Attorney:Attorney's name.
Attorney's address.
Attorney's city, state and zip code.
Date Child Placed in Petitioner’s Home: Date of placement.
Indian Child Welfare Act: The Indian Child Welfare Act Choose one.doesdoes notapply to Child's name.
Reason for Relinquishment and/or Deprivation:
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Briefly describe circumstances leading to termination of parental rights in one or two sentences.POST PLACEMENT REPORTPage 1 of 3
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Petitioner(s): Name of family.Background Check Completed on Date.
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Provide further details if there are issues that need to be addressed.POST PLACEMENT REPORTPage 1 of 3
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Adjustment of Child in the Home:Include description of child’s current development, attachment to adoptive family, attitude toward adoption if applicable. Describe any special needs of the child and how these needs are being met by the adoptive family. Include educational information.
Adjustment of Family to Child:
A brief summary of how the adoptive family is adjusting to placement of the child. If there are special needs of the child, how is the family accommodating those needs?
Family’s Policy, Practices and Rules for Food and Discipline:
A description of the family's approach to discipline. Specifically address if family withholds food as a discipline method.
Financial and Housing:
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A brief description of the family's home environment including financial and housing circumstances. Provide further detail if there are issues that need to be, or are being, addressed in these areas.POST PLACEMENT REPORTPage 1 of 3
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Medical:POST PLACEMENT REPORTPage 1 of 3
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A brief description of the adoptive parent's health. If medical issues, detail how those were assessed and addressed.POST PLACEMENT REPORTPage 1 of 3
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Who has Authority to Consent: DSHSDoes DSHS Consent: Yes
Name Change: Child’s adopted name if known. If unknown, report that (child’s name) adoptive name is unknown at the time of this report.
Recommendations: Adoption of Child's nameby Adoptive family's nameis recommended.
Date
Social Worker's Name, Adoption Specialist
Division of Children and Family Services
Department of Social and Health Services
Date
Supervisor's Name, Supervisor
Division of Children and Family Services
Department of Social and Health Services
Attachments:
Attachments are optional.
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/ Statement of Qualifications andVerification of Issues Discussed
I, , make the following declaration.
1.I am a Social Worker with the Department of Social and Health Services assigned to provide adoption services including completion of the post-placement report. I have the following qualifications to prepare post-placement adoption reports pursuant to RCW 26.33.
A Master's Degree and at least one year of experience in social work;
A Bachelor's Degree and at least two years of experience in social work;
Training within the Department in adoption practice;
Experience in matters pertaining to adoptions and in preparing adoption reports for years with the Department of Social and Health Services.
2.Written information regarding the Department’s post adoption related services has been provided to Petitioner's Name.
Adoption Support Adoption non-recurring costs Other:
I am the author of this report, know the contents thereof, and believe that statements included therein to be true. The recommendation is made based on the information available to me at the time of this report. Additional information may change my recommendation.
I am an employee of the Department of Social and Health Services as a Social Worker, assigned to provide adoption services including completion of post placement report.
This report was completed on .
I declare under penalty of perjury, under the laws of the State of Washington, that the forgoing is true and correct.
Signed on at , Washington.
SOCIAL WORKER’S SIGNATUREDATE
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