AUTOBIOGRAPHY OUTLINE - Lifetree Adoption Agency

Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
Dear Prospective Adoptive Family,
I would like to personally thank you for inquiring about Lifetree Adoption Agency. Lifetree is a
licensed child-placing agency thru the State of Texas. I know how you feel about having that
desire to become a “mom” and isn’t it great to know that only God can put that desire in our
hearts. God has a great plan for you. He will bless you one day and make you that “mom” or
“dad.” I know because I too was in your shoes. I thank God every day because He did answer
my prayers and He did fulfill my desire to become that “mom.” Because of those answered
prayers, I feel as though God is leading me to make other people that “mom” or “dad” they so
desire and to provide peace to those loving, courageous, and the most unselfish women I know
who aren’t yet ready to become that “mom” at this time in their life. This is why I decided to
open Lifetree Adoption Agency.
The initial step of your adoption journey is requesting Lifetree Adoption Agency’s informational
packet. After reading Lifetree Adoption Agency’s informational packet, I know you will have
many questions and I would enjoy meeting you to answer all of your questions in an intimate
setting.
Once I receive your application packet and the associated application fee of $2,500, I will
contact you to discuss the additional steps in completing the adoption process.
I look forward to guiding you in your adoption journey, and again, please don’t hesitate to
contact me if you should have any questions. Let Lifetree Adoption Agency help you find your
light at the end of the tunnel! I will continue to pray for you!
God Bless,
Lifetree Adoption Agency, LLC
Robin Stephenson
Robin Stephenson
Owner
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTIVE FAMILY APPLICATION PACKET
As part of Lifetree Adoption Agency’s Application Packet, please complete the following
application and attach the documents listed below. Once the Application Packet is complete,
please send the application to the address identified above along with the Application Fee in the
amount of $2,500. Please do not send any documentation which needs to be returned to you.
Recent family photograph
Driver’s License for you and your spouse
Social Security Card for you and your spouse
Passport for you and your spouse (if applicable)
Birth Certificate for all household members (including children, if applicable)
Autobiography of yourself and your spouse
Physical Examination (signed by a physician) for all persons living in the
household (must be less than 1 year since last visit)
Health Insurance Card (front and back)
Life Insurance Policy (if applicable)
(showing coverage amount & beneficiary)
Marriage Certificate
Divorce Decree or Death certificate (if applicable)
Most recent Tax Return
Most recent Paycheck Stub of all persons living in the household
Floor Plan of your home (showing dimensions and purposes of ALL rooms)
Sketch/Photographs of all Outside Play Areas
Vaccination Record of all family pets
CPR/First-aid Certificate for you and your spouse
Five References (using the attached form). Three of the references are
to be from different friends whom have known you longer than 5 years
and two of the references are to be from different family members. Your
friends/family members can fax their completed reference to LIFETREE
at the number listed above, email to [email protected], or
give it back to you in a sealed envelope.
Three copies of your photo album. The outline is attached and is entitled
“Adoptive Family Profile.”
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTIVE FAMILY APPLICATION
Please complete the following application. If you need additional room to answer a question,
please mark "See Attached" and add to the end of application. We ask that you please complete
the questionnaire as a couple.
Name of Adoptive Family:
Home Address:
(include city, state, zip code)
County:
Home Telephone Number:
Husband
Wife
Child(ren)
Full Name:
Other Names Used:
(Maiden name/nicknames)
SSN:
DLN and State:
Date of Birth:
Place of Birth:
Telephone Nos.
Mobile:
Work:
e-mail address:
NA
NA
NA
Citizenship:
Language Spoken:
Race:
Religious Preference:
Weight:
Height:
Hair Color:
Eye Color:
Skin Tone:
Application
R.02.14
Page 1 of 32
1. List ALL the cities in Texas each of you have lived?
Husband:
Wife:
2. List each of your residence history dating back 10 years.
Address, City, State & Zip Code
Length of Time
Husband:
Wife:
3. Employment History dating back 10 years.
Employer
Position
(Include Address)
Tenure
Husband:
Wife:
4. Level of education and present income.
Level of Education
Income
(Include Name of School)
Husband:
Wife:
5. Financial Status.
STATEMENT OF ASSETS & LIABILITIES
ASSETS
LIABILITIES
Cash:
Bank:
Other:
Application
R.10.13
Mortgages:
Page 2 of 32
Other:
Notes Payable:
Taxes Owing:
Securities:
Income:
Net Cash Value:
Insurance:
Annuities:
Other:
Account’s Payable:
Credit Card Debt:
Real Estate:
Personal Property &
Automobiles:
Furnishings:
Other Liabilities:
TOTAL LIABILITIES:
Collectibles
Vehicles:
TOTAL ASSETS:
LESS TOTAL LIABILITIES:
Other Assets:
TOTAL NET WORTH:
TOTAL ASSETS:
6.
Please explain how you will have the funds available for the adoption process.
7. Date of Marriage:
8. If either of you have had previous marriages, please briefly explain the date of marriage,
date of termination, and the reason for termination (i.e., death, divorce, etc.).
9. Do either of you have any health or medical problems? If yes, please describe the problem,
current medical status, and date of illness or disability.
10. Have either of you been arrested or convicted of a crime? No
Application
R.10.13
Page 3 of 32
If yes, please describe the nature of the crime:
11. Please share both of your positive and negative traits, and describe your personalities.
12. Are there any other persons living full time in your home? If yes, please complete the
following:
Name
DOB
Sex (M/F)
Relationship
Male
Male
13. Give the name, date of birth, and date of death (if applicable) of your children not presently
living in your home.
Name
DOB/DOD
Sex (M/F)
Relationship
Male
Male
Male
14. Give a brief description of your home (i.e., number of bedrooms, baths, living areas, back
yard, etc.).
15. Do you have any pets living at your home? No If Yes, please provide a brief description of
your pet(s):
16. Please provide five references whom we may contact. Be sure to choose three friends (with
whom you are well acquainted and who has known you for longer than 5 years) and two
family members.
NAME
ADDRESS
TELEPHONE #
EMAIL ADDRESS
Ref #1
Ref #2
Application
R.10.13
Page 4 of 32
Ref #3
Ref #4
Ref #5
17. What do you both do for fun (together and separately)?
18. Has there been a worthwhile experience that you shared together as a couple?
19. What would you say were some goals you both would like to achieve in your future
together?
20. Do you mind sharing what your most rewarding experience and your most heartbreaking
moment may be?
Rewarding Experience:
Heartbreaking Moment:
21. How would you describe a healthy self-esteem and sense-of-worth in your family unit?
22. Does God play a large part in each of your lives? What is your religious preference? How
often do you both attend church?
23. What values and belief systems do you think a family unit should consist of?
24. Can you describe the ways you show love and affection towards those you are close to,
especially towards a child?
Application
R.10.13
Page 5 of 32
25. How would you describe a healthy relationship between parent and child?
26. What roles do you think a father plays in the life of a child?
27. What roles do you think a mother plays in the life of a child?
28. Can you describe the way a child shows affection?
29. How would you feel if your child does not react and attach importance to the same matters
that are important to you (i.e., affection, education, types of discipline)?
30. In what ways do you plan on disciplining your child?
31. How do you think you will react and feel towards the way your child displays his/her feelings
of anger, fear, and anxiety?
32. What sort of goals do you have for your child?
33. What educational aspirations do you have for your child?
34. If you cannot have children biologically, please explain (i.e., infertility issues).
35. Why do you desire to adopt? How did you come to that conclusion?
Application
R.10.13
Page 6 of 32
36. Did both of you desire to adopt?
37. Can you express your concerns and fears regarding adoption?
38. How would you describe your feelings toward adoption?
39. How do you feel about Birth Parent(s) who place their child for adoption?
40. Do you have any fears about meeting the Birth Parent(s)?
41. What type of information are you both willing to share with the Birth Parent(s)? Would both
of you be willing to meet the Birth Parent(s) with an agency counselor assisting the
meeting? To answer these questions, consider the type of adoption scenario (semi-open,
open, closed) that meets your level of comfort.
42. What would you say or do if your child someday asks you about his/her Birth Parents?
43. What type of child do you both desire to parent? Is there an age range? Is there an ethnic
preference? What type of child are you both drawn to?
44. Are there any physical, medical, or social issues or any condition you feel uncomfortable
accepting in a child?
45. Can you explain the type of child you feel most distant towards?
Application
R.10.13
Page 7 of 32
46. Would you decline a placement if you felt uncomfortable about the child?
47. What are your plans for child care if both of you plan on working full time?
48. How would you describe a healthy sibling relationship?
49. How would you deal with conflict between your adopted child and other children that may be
living in your home?
50. Have you worked with another adoption agency? If so, please provide the name and
telephone number of the agency.
51. How did you learn about Lifetree Adoption Agency?
Based on the above information, we, the Adoptive Family, have completed this application in an
open and honest way and find it to be true and complete to the best of our knowledge.
By signing this application, each of you authorizes Lifetree Adoption Agency, LLC:
□ to conduct the background checks as required by Licensing;
□ to use the above and foregoing information in making a study of our
application; and
□ to discuss the contents of this application and our file with LIFETREE’s
contracted social worker and any other agency or adoption consultant
involved in our case.
SIGNED, upon this _________ day of _______________, 20___.
__________________________________ __________________________________
Application
R.10.13
Page 8 of 32
Name of Adoptive Parent
Signature of Adoptive Parent
__________________________________ __________________________________
Name of Adoptive Parent
Signature of Adoptive Parent
Application
R.10.13
Page 9 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTIVE FAMILY PROFILE
Your Family Photo Album/Scrapbook/Profile can be designed in any fashion that you desire. A
Family Photo Album is a great way to express who you are as a family, your interests, your
pets, a glimpse of your home, etc. through pictures. It allows the Birth Family to see what your
family life is like to where she can imagine the type of life her child will be living in your home
and the things her child will be doing with your family. When designing your Family Photo
Album, I always recommend putting yourself in the Birthmother’s shoes and try to imagine how
you would want your family’s story to be told. Since almost everything is digital these days, you
can design your Family Photo Album using many on-line photo services websites (i.e., Snapfish,
Shutterfly, Flickr, etc.)
You can also include the following information in your Family Flyer. A Family Flyer is a
laminated page that includes a brief glimpse of your family and the information outlined below.
This Family Flyer is what we use for prospective Birth Families to take away with them if they
are considering you as their adoptive family.
The following are guidelines for preparing your Family Photo Album and Family Flyer:
“Dear Birthmother” letter
Name
Age
Eye Color
Hair Color
Height
Education
Type of employment work (not name of employer)
Other family members (immediate and extended)
Hobbies and interests
Pets (Birth Families love seeing pictures of your pets!)
Number of years you have been married
Religion preference
Identify you child-care plans
Friends
Vacations
Your home (show views of outside and inside areas)
Your “Dear Birthmother” letter is your creation. Please try to expresses who you are in the
letter, how you and your spouse come to the decision of adopting, what type of life you can
provide for the child, identifying your child-care plans, and thanking the Birthmother for
reviewing your Family Photo Album. You can include favorite Bible passages that are close to
your heart.
Feel free to call us about ideas on how to put it together or how to do it!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTIVE FATHER AUTOBIOGRAPHY
Please prepare an autobiography for each of you. The purposes of the autobiography is to help
LIFETREE get to know you better by learning about your background, how you were raised,
your family experiences, etc. and to prepare us for the Adoptive Home Screening (aka Home
Study). Please write in narrative form rather than short sentences. We realize it is difficult for
some people to express themselves in writing; therefore, please do not concern yourselves with
correct grammar or spelling, as it is the content that interests us.
The autobiography should include the following information. Once completed, please forward
your autobiography to Lifetree Adoption Agency.
Childhood
1. Where were you born and what date?
2. What is the ethnic origin of your family?
3. Describe your parents and your relationship with them. Tell about your parents’ employment
and level of education. What was your parents’ occupation during your childhood years?
How many brothers/sisters do you have? What position were you in the family (oldest,
middle, youngest).
4. Who disciplined you the most; what form of discipline was used; and for what misbehavior
was it used?
5. Describe some unpleasant childhood memories.
6. What memories do you have about school?
7. Did you have any relatives with whom your family spent a lot of time with (i.e., holidays,
vacations, etc.)? Describe your favorite relative.
8. What do you wish your parents would have done differently?
9. What values did your parents try most to impress upon you?
Teen Years
10. Describe your school experiences (i.e., “best friends”, activities, interests, accomplishments,
favorite classes, etc.).
Adoptive Father Autobiography
Page 13 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
11. Describe your relationship with your parents during this time. How were you disciplined and
for what reason?
12. Describe your dating habits. At what age were you allowed to date? What activities did you
enjoy?
13. What responsibilities did you have at home?
14. How important is education to your parents? How important is education to you?
15. Did you complete high school? College? Vocational Training?
16. Were you ever in the Military? No
17. What were you likes/dislikes about this period of your life?
18. Did you join any clubs, groups, or other organizations?
19. What significant experiences did you have during these years which you feel affected you
later on? How did it affect you?
20. Did you feel the discipline your parents used was appropriate? If no, what would you do
differently?
Adulthood
21. Describe yourself (i.e., personality, interests, physical description, etc.)
22. How do you feel about your vocation (likes/dislikes)?
23. What are some of your individual interests?
24. If you could change anything about your current situation, what would it be?
25. Are you a member of any civic group? If so, what are they, why do you belong, and what is
the extent of your involvement?
26. What is your current state of health? Have you ever had any serious illnesses or
operations? Do you have any disabilities/handicaps?
27. Have you ever received any counseling or therapy? No
If so, what did you gain from it?
Adoptive Father Autobiography
Page 14 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
28. How do you feel you have changed over the years of marriage? How has your spouse
changed?
29. If you have any children:
 When and where were they born?
 Are they adopted?
 Are they in school? No If so, what grade?
How do they do in school?
 Describe them briefly – their personalities and interests.
 What form of discipline is used most often, and which parent disciplines?
Previous Marriages
30. Were there children by your previous marriage? No
If so, where are they now?
31. Who has custody?
32. Do you visit them or pay child support?
33. Why did you and your previous spouse divorce?
Adoptive Father Autobiography
Page 15 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTIVE MOTHER AUTOBIOGRAPHY
Please prepare an autobiography for each of you. The purposes of the autobiography is to help
LIFETREE get to know you better by learning about your background, how you were raised,
your family experiences, etc. and to prepare us for the Adoptive Home Screening (aka Home
Study). Please write in narrative form rather than short sentences. We realize it is difficult for
some people to express themselves in writing; therefore, please do not concern yourselves with
correct grammar or spelling, as it is the content that interests us.
The autobiography should include the following information. Once completed, please forward
your autobiography to Lifetree Adoption Agency.
Childhood
1. Where were you born and what date?
2. What is the ethnic origin of your family?
3. Describe your parents and your relationship with them. Tell about your parents’ employment
and level of education. What was your parents’ occupation during your childhood years?
How many brothers/sisters do you have? What position were you in the family (oldest,
middle, youngest).
4. Who disciplined you the most; what form of discipline was used; and for what misbehavior
was it used?
5. Describe some unpleasant childhood memories.
6. What memories do you have about school?
7. Did you have any relatives with whom your family spent a lot of time with (i.e., holidays,
vacations, etc.)? Describe your favorite relative.
8. What do you wish your parents would have done differently?
9. What values did your parents try most to impress upon you?
Teen Years
1. Describe your school experiences (i.e., “best friends”, activities, interests, accomplishments,
favorite classes, etc.).
Adoptive Mother Autobiography
Page 16 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
2. Describe your relationship with your parents during this time. How were you disciplined and
for what reason?
3. Describe your dating habits. At what age were you allowed to date? What activities did you
enjoy?
4. What responsibilities did you have at home?
5. How important is education to your parents? How important is education to you?
6. Did you complete high school? College? Vocational Training?
7. Were you ever in the Military? No
8. What were you likes/dislikes about this period of your life?
9. Did you join any clubs, groups, or other organizations?
10. What significant experiences did you have during these years which you feel affected you
later on? How did it affect you?
11. Did you feel the discipline your parents used was appropriate? If no, what would you do
differently?
Adulthood
1. Describe yourself (i.e., personality, interests, physical description, etc.)
2. How do you feel about your vocation (likes/dislikes)?
3. What are some of your individual interests?
4. If you could change anything about your current situation, what would it be?
5. Are you a member of any civic group? If so, what are they, why do you belong, and what is
the extent of your involvement?
6. What is your current state of health? Have you ever had any serious illnesses or
operations? Do you have any disabilities/handicaps?
7. Have you ever received any counseling or therapy? No
If so, what did you gain from it?
Adoptive Mother Autobiography
Page 17 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
8. How do you feel you have changed over the years of marriage? How has your spouse
changed?
9. If you have any children:
 When and where were they born?
 Are they adopted?
 Are they in school? No If so, what grade?
How do they do in school?
 Describe them briefly – their personalities and interests.
 What form of discipline is used most often, and which parent disciplines?
Previous Marriages
1. Were there children by your previous marriage? No
If so, where are they now?
2. Who has custody?
3. Do you visit them or pay child support?
4. Why did you and your spouse divorce?
Adoptive Mother Autobiography
Page 18 of 32
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
[email protected]
www.LifetreeAdoption.com
PERSONAL REFERENCE OUTLINE
(Please use friends who have known you longer than five years)
Name of Adoptive Family:
1. What is your relationship to this family?
2. How long have you known this family?
Husband: _______
Wife: _______
As a couple: _______
3. How would you describe this family’s personality?
Wife:
Husband:
4. What problems, if any, would you say this couple has?
5. What does this couple like to do for fun? Do you know of any hobbies?
6. Do they have any experience with children?
7. Describe the skills that this family possesses that will be helpful in raising a child by
adoption?
8. If you have children, would you ever leave your children in the care of this family?
Why/Why not?
9. How would you describe their marriage? (Circle One) Average
Any additional comments:
Exceptional
Unhappy
10. Do you feel that either person has any negative influences such as drinking, substance
abuse (drugs), gambling, poor health, financial, problems with the law, or emotional
problem(s)?
11. If you were responsible for a child’s future, would you recommend placing a child into
this couple’s home?
12. Are there any other issues or concerns that you would like to share?
________________________________
Signature
_______________________________
Date
________________________________
_(____)_________________________
________________________________
Phone
Address
Please return this completed form to the address above.
You may use the back of this form if more space is needed.
Thank you for your help!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
[email protected]
www.LifetreeAdoption.com
PERSONAL REFERENCE OUTLINE
(Please use friends who have known you longer than five years)
Name of Adoptive Family:
1. What is your relationship to this family?
2. How long have you known this family?
Husband: _______
Wife: _______
As a couple: _______
3. How would you describe this family’s personality?
Wife:
Husband:
4. What problems, if any, would you say this couple has?
5. What does this couple like to do for fun? Do you know of any hobbies?
6. Do they have any experience with children?
7. Describe the skills that this family possesses that will be helpful in raising a child by
adoption?
8. If you have children, would you ever leave your children in the care of this family?
Why/Why not?
9. How would you describe their marriage? (Circle One) Average
Any additional comments:
Exceptional
Unhappy
10. Do you feel that either person has any negative influences such as drinking, substance
abuse (drugs), gambling, poor health, financial, problems with the law, or emotional
problem(s)?
11. If you were responsible for a child’s future, would you recommend placing a child into
this couple’s home?
12. Are there any other issues or concerns that you would like to share?
________________________________
Signature
_______________________________
Date
________________________________
_(____)_________________________
________________________________
Phone
Address
Please return this completed form to the address above.
You may use the back of this form if more space is needed.
Thank you for your help!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
[email protected]
www.LifetreeAdoption.com
PERSONAL REFERENCE OUTLINE
(Please use friends who have known you longer than five years)
Name of Adoptive Family:
1. What is your relationship to this family?
2. How long have you known this family?
Husband: _______
Wife: _______
As a couple: _______
3. How would you describe this family’s personality?
Wife:
Husband:
4. What problems, if any, would you say this couple has?
5. What does this couple like to do for fun? Do you know of any hobbies?
6. Do they have any experience with children?
7. Describe the skills that this family possesses that will be helpful in raising a child by
adoption?
8. If you have children, would you ever leave your children in the care of this family?
Why/Why not?
9. How would you describe their marriage? (Circle One) Average
Any additional comments:
Exceptional
Unhappy
10. Do you feel that either person has any negative influences such as drinking, substance
abuse (drugs), gambling, poor health, financial, problems with the law, or emotional
problem(s)?
11. If you were responsible for a child’s future, would you recommend placing a child into
this couple’s home?
12. Are there any other issues or concerns that you would like to share?
________________________________
Signature
_______________________________
Date
________________________________
_(____)_________________________
________________________________
Phone
Address
Please return this completed form to the address above.
You may use the back of this form if more space is needed.
Thank you for your help!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
[email protected]
www.LifetreeAdoption.com
PERSONAL REFERENCE OUTLINE
(Please use family member)
Name of Adoptive Family:
13. What is your relationship to this family?
14. How long have you known this family?
Husband: _______
Wife: _______
As a couple: _______
15. How would you describe this family’s personality?
Wife:
Husband:
16. What problems, if any, would you say this couple has?
17. What does this couple like to do for fun? Do you know of any hobbies?
18. Do they have any experience with children?
19. Describe the skills that this family possesses that will be helpful in raising a child by
adoption?
20. If you have children, would you ever leave your children in the care of this family?
Why/Why not?
21. How would you describe their marriage? (Circle One) Average
Any additional comments:
Exceptional
Unhappy
22. Do you feel that either person has any negative influences such as drinking, substance
abuse (drugs), gambling, poor health, financial, problems with the law, or emotional
problem(s)?
23. If you were responsible for a child’s future, would you recommend placing a child into
this couple’s home?
24. Are there any other issues or concerns that you would like to share?
________________________________
Signature
_______________________________
Date
________________________________
_(____)_________________________
________________________________
Phone
Address
Please return this completed form to the address above.
You may use the back of this form if more space is needed.
Thank you for your help!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
[email protected]
www.LifetreeAdoption.com
PERSONAL REFERENCE OUTLINE
(Please use family member)
Name of Adoptive Family:
13. What is your relationship to this family?
14. How long have you known this family?
Husband: _______
Wife: _______
As a couple: _______
15. How would you describe this family’s personality?
Wife:
Husband:
16. What problems, if any, would you say this couple has?
17. What does this couple like to do for fun? Do you know of any hobbies?
18. Do they have any experience with children?
19. Describe the skills that this family possesses that will be helpful in raising a child by
adoption?
20. If you have children, would you ever leave your children in the care of this family?
Why/Why not?
21. How would you describe their marriage? (Circle One) Average
Any additional comments:
Exceptional
Unhappy
22. Do you feel that either person has any negative influences such as drinking, substance
abuse (drugs), gambling, poor health, financial, problems with the law, or emotional
problem(s)?
23. If you were responsible for a child’s future, would you recommend placing a child into
this couple’s home?
24. Are there any other issues or concerns that you would like to share?
________________________________
Signature
_______________________________
Date
________________________________
_(____)_________________________
________________________________
Phone
Address
Please return this completed form to the address above.
You may use the back of this form if more space is needed.
Thank you for your help!
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
www.LifetreeAdoption.com
PHYSICAL EXAM
Last Name:
First Name:
Age:
Name, Address, Phone Number of Physician:
PRESENT CONDITION
Weight:
Height:
Blood Pressure:
Heart Rate:
Maintenance medication:
General physical condition:
How long has this patient been known to you?
MEDICAL HISTORY
Yes
*
Is the applicant in good mental and physical health?
*
Does the applicant have a personal or family history of any significant disease(s)
or chronic disabling condition(s)
*
Does the applicant suffer from any communicable disease(s)?
*
Has the applicant ever been hospitalized?
*
Has the applicant ever been treated for emotional problems or mental illness(es)?
*
Has the applicant ever been treated for chemical dependency?
*
Is the applicant expected to have a normal life span?
*
Has the applicant undergone infertility tests and/or treatment?
No
If the answer to any of the above questions is “yes,” what implications might this have for the applicant’s
functioning as an adoptive parent?
Physician’s Signature
Date of Exam
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I hereby authorize my physician or
clinic to release any medical information pertinent to the application to LIFETREE ADOPTION AGENCY,
LLC.
Signature of Adoptive Parent
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
www.LifetreeAdoption.com
PHYSICAL EXAM
Last Name:
First Name:
Age:
Name, Address, Phone Number of Physician:
PRESENT CONDITION
Weight:
Height:
Blood Pressure:
Heart Rate:
Maintenance medication:
General physical condition:
How long has this patient been known to you?
MEDICAL HISTORY
Yes
*
Is the applicant in good mental and physical health?
*
Does the applicant have a personal or family history of any significant disease(s)
or chronic disabling condition(s)
*
Does the applicant suffer from any communicable disease(s)?
*
Has the applicant ever been hospitalized?
*
Has the applicant ever been treated for emotional problems or mental illness(es)?
*
Has the applicant ever been treated for chemical dependency?
*
Is the applicant expected to have a normal life span?
*
Has the applicant undergone infertility tests and/or treatment?
No
If the answer to any of the above questions is “yes,” what implications might this have for the applicant’s
functioning as an adoptive parent?
Physician’s Signature
Date of Exam
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I hereby authorize my physician or
clinic to release any medical information pertinent to the application to LIFETREE ADOPTION AGENCY,
LLC.
Signature of Adoptive Parent
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
(972) 233-4576 (fax)
www.LifetreeAdoption.com
INSURANCE INFORMATION
Life Insurance
Life Insurance Carrier
(Include Address)
Amount
$
Beneficiary
Husband:
Wife:
Medical and Health Insurance
Health Insurance Provider
(Include Address and Telephone Number)
Amount of
Coverage
$
Amount of
Deductible
$
Who’s
Covered
Husband:
Wife:
We authorize Lifetree Adoption Agency, LLC to contact our Insurance Carriers and for our
Insurance Carriers to provide Lifetree Adoption Agency, LLC the needed information to use the
above and foregoing information in making a study of our application.
Note: Both parties must sign this form to be valid.
Name of Husband
Name of Wife
Signature of Husband
Signature of Wife
Date
Date
Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
ADOPTION EXPECTATIONS
These are parameters used to assist Lifetree Adoption Agency in the matching process. The
parameters are also considered to be the most important issues in accepting or declining the match.
The more open your parameters are, the shorter your wait time may be. However, you are
encouraged to set your parameters where you are comfortable with the understanding that the wait
time may increase. Please remember that your child will grow up the way he or she is raised. Just
because the Birthmother may not be in school or have what you think is an ideal lifestyle DOES NOT
mean that the child cannot thrive scholastically and prove to be successful. LIFETREE will contact
you on a quarterly basis to verify the accuracy of your adoption expectations.
NAME OF ADOPTIVE FAMILY:
1.0
EXPECTATIONS FOR ADOPTIVE PLACEMENT
1. GENDER:
Sonograms are performed by the Birthmother’s Obstetrician and are conducted for MEDICAL REASONS only.
The reasons are, but not limited to, determining the developmental progress and health of the child. LIFETREE
does not request sonograms for the sole purpose of determining gender. Gender determination by a sonogram
IS NOT always accurate. LIFETREE will not guarantee gender and we cannot have you turn a child down at
the hospital because of the wrong gender. LIFETREE also cannot give an approximate wait time for families
who have a gender preference.
Open
Male
Female
2. CHILD’S AGE RANGE:
3.
Newborn only
0-3 months
3-6 months
6-12 months
12-24 months
1-2 years
2-3 years
Open to All
RACE/ETHNICITY:
Completely open
FOR INTERNAL USE ONLY
Caucasian
Hispanic
African-American
Asian
Bi-racial:
Caucasian/Hispanic
Caucasian/African-American
Hispanic/African-American
Asian/African-American
Date of Approval:
Quarterly Reviews: Date
Changes?
1:
Y
N
2: Caucasian/Asian Y
N
3:
Y
N
4:
Y
N
5:
Y
N
6:
Y
N
Other:
Adoption Expectations
R.01.14
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4.
HEALTH ISSUES
Healthy ONLY
Minor correctable handicaps
Chronic minor handicaps
Special needs
5.
PREMATURITY
Okay
No
Depends
Need more time to decide
Up to 34 weeks gestation
Beyond 34 weeks gestation
6.
MULTIPLES
Would consider
Would not consider
Twins
Siblings
If yes, number of children would be open to:
Age range for youngest:
7.
Age range for oldest:
BIRTHMOTHER’S SUBSTANCE USE/CHILD’S EXPOSURE
If you have any concerns about drug, alcohol, or nicotine exposure during pregnancy, please consult your
physician. Marking that you would consider a situation with any of these substances does not mean you would
accept it. It only means that you would want to consider it.
NOTE: Drug screens are not performed by LIFETREE; however, LIFETREE may request the Birthmother’s
Obstetricians to evaluate the Birthmother’s substance abuse history. Please remember that any drug screening
performed by the Obstetrician is only a test of drugs in the system for a period of time. LIFETREE NEVER
guarantees that the Birthmother has not used drugs during her pregnancy. We do our best, however, to provide
you with the information.
Would consider
Would not consider
Would consider
Smoking:
Amphetamines:
Alcohol:
Barbiturates:
Marijuana:
Cocaine:
Would not consider
Heroin
Adoption Expectations
R.01.14
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8.
PLACEMENT SITUATIONS
YES
NO
Would you consider a child who was a result of a rape (date or random)?
Would you consider a Birth Parent who already has a child(ren)?
Would you consider a Birth Parent who lives in your Metroplex?
Would you consider a Birth Parent who is married/common-law married?
Would you consider a drop-in placement?
A drop-in placement is defined as a Birthmother/hospital contacting LIFETREE after the Child is born. And, LIFETREE does not know much about the Birthmother,
Birthfather, and/or Child. Also, LIFETREE does not know about the Birthmother’s prenatal care and/or the Child’s exposure to drug(s).
Would you be willing to meet with the Birth Family if she is deciding between
you and another potential Adoptive Family in order to help her make a decision?
9.
BIRTHFATHER SITUATIONS
The law does not require LIFETREE to notify the birthfather of the pregnancy or birth. His responsibility is to
notify the State Paternity Registry, if he desires, within 31 days to try and establish a legal relationship to the
child or contract with an attorney prior to his parental rights are terminated. He is charged with knowledge of the
pregnancy by having had a sexual relationship with the Birthmother. A legal father is one who is either married
to the Birthmother or is identified on the Birth Certificate (the Birthfather has to sign an Acknowledgement of
Paternity) and one who must give consent or be served with due process.
Would consider
Would not consider
Unknown Birthfather:
The Birthmother knows only a limited amount of information about the Birthfather. She may only know
his first name and possibly a physical description.
Known/ Whereabouts Unknown:
Birthfather is known but his whereabouts are unknown. She may or may not know him very well.

Birthfather is contacted and he doesn’t want to provide any information

Attempts to contact Birthfather, but he doesn’t return messages
NOTE: A known Birthfather DOES NOT guarantee receiving his Health, Social, Education and Genetic
History (HSEGH) Report information.
Known Birthfather:
The Birthmother knows who he is and where he is. The Birthfather is known and willing to provide his
HSEGH Report information.
Adoption Expectations
R.01.14
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2.0
ADOPTION SCENARIO ELECTED
Y
N
Semi-open:
Open Adoption:
Closed Adoption:
3.0
THE DEGREE AND TYPE OF INVOLVEMENT DESIRED WITH THE BIRTH PARENTS
Unless you choose a completely open adoption, ALL of your continuing contacts are facilitated through LIFETREE.
There is no disclosure, if elected, of identifying information and all pictures, letters, cards, gifts, etc. are seen by
LIFETREE before passed on to the receiving party. LIFETREE will execute a continuing contact agreement signed
by both Birth and Adoptive Families.
LIFETREE’s minimum requirement for continuing contact is that the Adoptive Family must send pictures and
letters to the Birth Family every other month for the first year and then annually after that until the child reaches the
age of 18. At least 10 pictures must be sent each time along with a personal letter updating the Birth Family on the
child. This is a sacred PROMISE and commitment and failure to comply could result in legal action. Sending
pictures and letters to the Birth Family via email (or other means) is not only beneficial for you and the Birth Family,
it is also a way to honor the child and to get answers to questions the child may have in the future.
Prior to placement:
Yes
No
Willing to have little or no relationship with the Birth Family
Willing to have face-to-face meetings with Birth Family
Willing to exchange/disclose full name, address, and phone number
Willing to provide written communication to Birth Family
Willing to have conference calls with Birth Family and a LIFETREE caseworker
Willing to attend labor and deliver
Willing to care for baby in hospital
Willing to assume temporary foster care
After placement:
Yes
No
Agree to pictures/correspondences requirement for 18 years
Willing to write letters and send pictures for
years
Willing to have face-to-face meetings with Birth Family
Willing to have conference calls with Birth Family
Willing to send a video to Birth Family for a
number of years
Willing to commit yearly face-to-face meetings with the Birth Family for
times per year and
years
Willing to accept cards, letters, pictures, birthday/Holiday gifts, etc. from the Birth Family
Adoption Expectations
R.01.14
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If there are other important issues that you specifically need to have addressed prior to a match, please address
those here:
4.0
WHAT DO THE ADOPTIVE PARENTS DESIRE FROM THE BIRTH FAMILY
5.0
EXPLAIN THE NEEDS AND RESPONSIBLITIES OF THE ADOPTIVE FAMILY
Needs:
Responsibilities:
Based on the above information, we, the Adoptive Family, have identified our expectations of the adoption process and we
completely understand what our responsibilities are as an Adoptive Family.
SIGNED, upon this _________ day of _______________, 20___.
__________________________________
Name of Adoptive Parent
__________________________________
Signature of Adoptive Parent
__________________________________
Name of Adoptive Parent
__________________________________
Signature of Adoptive Parent
_______________________________________
Signature of LIFETREE Caseworker
Adoption Expectations
R.01.14
Date
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Lifetree Adoption Agency
5220 Spring Valley Road, Suite 550
Dallas, Texas 75254
(972) 491-3333
www.LifetreeAdoption.com
Additional services and changes to this Adoption Expectations are listed as follows:
(This section to be completed by a LIFETREE Caseworker)
Service:
Action taken:
Is this an additional service or a changed service from the original plan?
Service:
Action Taken:
Is this an additional service or a changed plan?
Service:
Action Taken:
Is this an additional service or a changed plan?
__________________________________________
Signature of LIFETREE Caseworker
Adoption Expectations
R.01.14
Date
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