Report for State of Origin

Prospective Adopter’s Report (formerly Form F)(England) ICA

Intercountry adoption application

Report for State of Origin

FRONTSHEETS TO REPORT FOR STATE OF ORIGIN

The agency

Name of agency
Address
Postcode
Telephone / Fax
Name of social worker / Name of team manager
Telephone / Telephone
Minicom / Minicom
Fax / Fax
Email / Email

The applicants

Applicant 1 / Applicant 2
Full name
Nationality
Ethnic origin
Religion
Occupation
Confirmation that Criminal Record Bureau checks are clear with date of issue
Address
Email
Telephone
Partnership status
Children in the household with dates of birth
Children living elsewhere with date of birth
Other adults in the household
Confirmation that Criminal Record Bureau checks for above are clear with date of issue
Health status of applicants (and any children of the household)
Accommodation
Pets
Country of application
Approval details (age, sex, number of children plus key matching information, i.e special needs)

Please note that the assessment undertaken by the UK adoption agency includes preparation of prospective adoptive parents, statutory and safeguarding checks, home visits, interviews with referees (and where applicable testamentary guardians) and a health and safety report on the home.

Please see guidance notes for advice on completion of this report

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Prospective Adopter’s Report (formerly Form F)(England) ICA

Intercountry adoption application

Report for State of Origin

Applicant/s name/s:

Family of origin and significant relationships (including those that have ended), identity and personality (synopsis and analysis sections 1–3)

Education, employment, and hobbies (synopsis and analysis Sections 4–7)

Current relationship synopsis and analysis (section 8)

Current relationship synopsis and analysis (section 8)

Children of the household, children living elsewhere, other adult members of the household (synopsis and analysis sections 9–11)

Neighbourhood and community (section 12)

Financial circumstances (section 13)

Motivation for adoption (section 14)

Parenting experience and capacity including plans for lifestyle changes and availability of support (synopsis and analysis sections 15–17)

Applicant’s plans in the event of ill health, disability or death including arrangements for Guardians (section 18)

Applicant’s understanding of adoption issues, including the impact of the past, exploring adoption, contact and tracing (synopsis and analysis sections 19 and 20)

Characteristics of child/ren applicant/s is seeking to adopt (section 21)

Applicant’s attitudes towards diversity and difference and ability and plans to promote a child’s cultural, religious, linguistic heritage (synopsis and analysis sections 22 and 23)

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Prospective Adopter’s Report (formerly Form F)(England) ICA

Intercountry adoption application

Report for State of Origin

Overall analysis and evaluation

Analysis, evaluation and summary of key factors leading to the recommendation. This should identify the strengths, vulnerabilities and any areas for the applicant’s further development as an adopter

Recommendation to the panel

Using the analysis, evaluation and summary above, what is the recommendation to the panel about the suitability of the applicant/s to be approved as an adopter?

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Prospective Adopter’s Report (formerly Form F)(England) ICA

Intercountry adoption application

Report for State of Origin

Applicant consent to report for State of Origin

Name of applicant/s
I/We certify that, to the best of my/our knowledge and belief, the details contained in this report are correct. I/We understand that this report is for the purpose of the State of Origin.
I/We understand that any information supplied by me/us in respect of this application may be held and/or processed in an electronic form and is subject to the relevant provisions in the Data Protection Act 1998 and other relevant statutes. I/We understand that any information supplied will form part of the agency’s case record in respect of my/our application.
I/We understand that this form is the property of the agency to which I/we have applied. I/We agree not to copy this document (other than for my/our own personal records) or disclose its contents in full or in part, to any other person, agency or authority without the agency’s permission.
Signature
Print name
Date
Signature
Print name
Date

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Prospective Adopter’s Report (formerly Form F)(England) ICA

Intercountry adoption application

Report for State of Origin

Signature of social worker completing the report for state of origin
I certify that this report is compliant with the restriction on the preparation of adoption reports regulations 2005
Signature of social worker completing the report for State of Origin
Print name
Date
Signature of team manager responsible for the report for state of origin
I certify that this report is compliant with the Restriction on the Preparation of Adoption reports regulations 2005
Signature of team manager responsible for the report for State of Origin
Print name
Date
Panel recommendation/s (including, where appropriate, recommendation of IRM panel)
Agency decision
(state number, age and characteristics of child for whom approval is given and country concerned)
Signature of agency decision maker
Date
Print name and designation of decision maker and name of the council/adoption agency

Practical arrangements

Translation of documents
Name, address and phone number if known
Notarisation of documents
Name, address and phone number if known
Agency in State of Origin
Name, address, fax and phone number if known
To whom do applicant/s wish documents to be sent after Certificate of Eligibility is issued?
Name, address, fax and phone number if known

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Prospective Adopter’s Report (England) ICA

Useful appendices

Intercountry adoption application

Report for State of Origin

Post-placement/post-adoption undertaking to State of Origin

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Prospective Adopter’s Report (England) ICA

Useful appendices

Intercountry adoption application

Report for State of Origin

Matching considerations

The aim of this list is as an aid to the assessing social worker. It may be completed by the social worker and the applicant/s together at the end of the assessment process. It is intended to reflect more than just the wishes of the applicant/s: it should reflect an agreed position about the type of child or situation which is considered appropriate for the applicant/s, after having addressed the issues in depth during the preparation and assessment process.

There is no requirement to append this form to the Prospective Adopter’s Report provided that the section B and the report for the State of Origin cover the matching considerations.

PART ONE – THE CHILD
*Delete as appropriate / Would accept / Would not accept / Would consider
Child about whom little information is known
Child whose ethnic origin is unknown
Child whose health history may not be known
Child who may have been abandoned
Child with disfiguring facial characteristics
Child with treatable physical condition
Child with specific health needs, e.g. insulin dependency/epilepsy
Child with an unclear/unknown medical prognosis
Child who has lived in an institution for a considerable period of their life
Child whose ethnicity is different from that of the applicant/s
Child who has a high risk of developing a life-threatening infection/condition
Child with physical disability
Child who is Hepatitis B or Hepatitis C positive
Child who is HIV positive
Child with mental disability
Other
PART TWO – It would be helpful to complete this section in case the following
information is known by the authorities in the child’s country of residence
Would accept / Would not accept / Would consider
Child who may have been emotionally abused
Child who may have been physically abused
Child who may have been sexually abused
Child who may have difficulty bonding with carers over time
Child who may display overt behavioural difficulties
Child who may display sexualised behaviour
Child who may need special education provision
Child who is at risk of developing an inherited condition
Child born as a result of rape/incest
Child whose parent/both parents* have a serious physical disability
Child whose parent/both parents* have a serious mental disability
Child whose parent/both parents* have learning difficulties
Child whose parent/both parents* are intravenous drug users
Child whose parent/both parents* have misused alcohol
Other
*Delete as appropriate

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