Loving Houston Adoption Agency Offering Foster Care and ... · 5 WIFE If more space is needed,...

LovingHoustonAdoptionAgencyOfferingFosterCareandAdoptionServices

Questionnaire/Application

LastName FirstName(Husband) (Wife)Address: City: State: Zip: HomePhone: Husband:Cell: Work: Wife:Cell: Work: HusbandEmailcontact: WifeEmailcontact:

HUSBAND’SINFORMATIONAge DateofBirth Ethnicity Education Occupation PrimaryLanguage Otherlanguagesspoken Citizenship MarriageDate Divorce(s)?When?

WIFE’SINFORMATIONAge DateofBirth Ethnicity Education Occupation PrimaryLanguage Otherlanguagesspoken Citizenship MarriageDate Divorce(s)?When?

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CHILDREN:Name Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐No

Name Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐NoName Gender DateofBirth Age Ethnicity Education Livesinsidehome ☐Yes☐No

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PETS:Name Breed Indoor/Outdoor

DESCRIPTIONOFHOME:

1. Howlonghaveyouresidedatyourcurrentaddress? Years Months

2. Doyou(check):�Own�Rent/Lease�Mortgaged

3. Typeofneighborhood?(check)�Apartment�Rural�City�Town�Subdivisiona. #ofbedrooms #ofbathrooms

4. Whatwillbethesleepingarrangementsforthechild(children)youfoster/adopt?

5. Willthechild(children)besharingaroom?Ifyes,whichofyourchildrenwillbesharing

aroomwiththechild(children)?

6. Describeyourneighborhood,includingtheaverageincomelevel,ageofresidents,and

racialmakeup.

7. WhatIndependentSchoolDistrictareyouin?

8. Describeyourrelationshipwithyourneighbors.

CHURCHINFORMATION:

1. ChurchName:

2. Pastor’sName:

3. Isthehusbandamember(Check)�Yes�NoHowlong?

4. Ifthewifeamember(Check)�Yes�NoHowlong?

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RespondingtotheBiblicaladmonitiontopracticetrueandundefiledreligion(James1:27)LovingHoustonseekslike-mindedfamiliesincaringforthelittleones.Pleaseanswerthefollowingquestions.

HUSBANDIfmorespaceisneeded,pleaseattachanadditionalpagetothisform.ReadALLthequestionsfirstbeforeanswering.1.PleasewriteinyourownwordswhatagenuineChristianistoyou.2.DescribeyourconversionexperienceandexplainhowChristhaschangedyourlife.3.HowdoesyourChristianityaffectyourdailylife?(i.e.devotion,worship,interactionswithyourwork,family,spouse,etc)4.WhatdoesbeingaChristianhusbandandfathermeantoyou?5.Inyourunderstanding,whatisaChristianfamily?

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WIFEIfmorespaceisneeded,pleaseattachanadditionalpagetothisform.ReadALLthequestionsfirstbeforeanswering.1.PleasewriteinyourownwordswhatagenuineChristianistoyou.2.DescribeyourconversionexperienceandexplainhowChristhaschangedyourlife.3.HowdoesyourChristianityaffectyourdailylife?(i.e.devotion,worship,interactionswithyourwork,family,spouse,etc)4.WhatdoesbeingaChristianwifeandmothermeantoyou?5.Inyourunderstanding,whatisaChristianfamily?

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EMPLOYMENTINFORMATION:HusbandOccupation: CompanyName:

CompanyAddress:

City: Zip:

JobDescription(Pleasedescribejobdutiesandresponsibilities):Whatisyourdailyschedule?Doyouhaveanyflexibilityinyourschedule?Forexample,ifnecessary,canyouleaveworktotakeachildtodoctor/therapyappointments,schoolmeetings,biologicalfamily/siblingvisits?Howlonghaveyoubeenatcurrentjob? Years MonthsOnaseparatepieceofpaperpleaselistemploymentorbusinessforthelasttenyearsorsinceleavingschool.Pleaseincludethefollowing:a)Occupationb)Employerc)Datesd)Wage/SalaryWifeOccupation: CompanyName:

CompanyAddress:

City: Zip:

JobDescription(Pleasedescribejobdutiesandresponsibilities):Whatisyourdailyschedule?Doyouhaveanyflexibilityinyourschedule?Forexample,ifnecessary,canyouleaveworktotakeachildtodoctor/therapyappointments,schoolmeetings,biologicalfamily/siblingvisits?Howlonghaveyoubeenatcurrentjob? Years MonthsOnaseparatepieceofpaperpleaselistemploymentorbusinessforthelasttenyearsorsinceleavingschool.Pleaseincludethefollowing:a)Occupationb)Employerc)Datesd)Wage/Salary

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FINANCIALINFORMATION:MonthlyGrossIncome: Husband Wife

MonthlyNetIncome: Husband Wife

MonthlyExpenses Savings

Tithe Passbook

HousePayments Certificates

Utilities Stocks

Insurances U.S.Bonds

AutomobilePayment Other

Gasoline

Food

DebtPayments

ChildCare

Clothing

Medical

Pets

Legal(inc.attorneyfees,childsupport/alimony,etc.)

Misc./Other

TotalExpenses TotalSavings

LIFEINSURANCEINFORMATION:CompanyName:

ValueofPolicy: Husband Wife

Premium(monthlyorannually):Cost: Husband WifePleaseNote:OnlyincludecostifitisNOTreflectedinnetincome

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HEALTHINSURANCEINFORMATION:CompanyName:

TypeofCoverage(medical/dental):

Premium:MonthlyorAnnually(circleone)Amount:

Isthistakenoutinyourpaycheck?�YES�NOPleaseNote:OnlyincludethecostifitisNOTreflectedinnetincome.

RESIDENCES:Listthedatesandaddressesoftheplacesyouhaveresidedforthepast10yearsbeginningwiththecurrentaddress.

HusbandDates Address City State Zip

Wife

Dates Address City State Zip

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MEDICALINFORMATION-Husband(Pleaseuseadditionalpaperasneededforcompleteexplanation)

Handicaps Date DegreeofRecovery CurrentHealth

a)

b)

c)

ChronicConditions Date DegreeofRecovery CurrentHealth

a)

b)

c)

SeriousIllnesses Date DegreeofRecovery CurrentHealth

a)

b)

c)

Operations Date DegreeofRecovery CurrentHealth

a)

b)

c)

Abortion:Toyourknowledgehaveyoufatheredachildthatwassubsequentlyabortedormiscarried?Abortion: �Yes�NoMiscarried:�Yes�NoPleasebrieflyexplainanyemotionalsideeffectsandhowyouhaveresolvedorareattemptingtoresolvethisexperience?

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MEDICALINFORMATION-Wife(Pleaseuseadditionalpaperasneededforcompleteexplanation)

Handicaps Date DegreeofRecovery CurrentHealth

a)

b)

c)

ChronicConditions Date DegreeofRecovery CurrentHealth

a)

b)

c)

SeriousIllnesses Date DegreeofRecovery CurrentHealth

a)

b)

c)

Operations Date DegreeofRecovery CurrentHealth

a)

b)

c)

Abortion:Haveyoueverbeenpregnantwithachildthatwassubsequentlyabortedormiscarried?Abortion: �Yes�NoMiscarried:�Yes�NoPleasebrieflyexplainanyemotionalsideeffectsandhowyouhaveresolvedorareattemptingtoresolvethisexperience?

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FAMILYBACKGROUND:

Husband

NumberofBrothers: Adopted Step Biological

NumberofSisters: Adopted Step Biological

SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .

SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .

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HUSBAND’SPARENTSAreyourbiologicalparentsstillmarried?

�Yes,Howlong?

�No,Howlongweretheymarried?

Father Mother Name

Address

PlaceofBirth

Education

Occupation

Age

GeneralHealth

Deceased/Age

Causeofdeath

Frequency&TypeofContact

Step-Mother Step-Father Name

Address

PlaceofBirth

Education

Occupation

Age

GeneralHealth

Deceased/Age

Causeofdeath

Frequency&TypeofContact

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FAMILYBACKGROUND:

Wife

NumberofBrothers: Adopted Step Biological

NumberofSisters: Adopted Step Biological

SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .

SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .SiblingName: .Address: .D.O.B: .GeneralHealth: .Education: .MaritalStatus: .Occupation: .NumberofChildren: .Children’sAges: .Frequency&TypeofContact: . .

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WIFE’SPARENTSAreyourbiologicalparentsstillmarried?

�Yes,Howlong?

�No,Howlongweretheymarried?

Father Mother Name

Address

PlaceofBirth

Education

Occupation

Age

GeneralHealth

Deceased/Age

Causeofdeath

Frequency&TypeofContact

Step-Mother Step-Father Name

Address

PlaceofBirth

Education

Occupation

Age

GeneralHealth

Deceased/Age

Causeofdeath

Frequency&TypeofContact

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PREVIOUSMARRIAGE(S):Husband Wife ToWhom DateofMarriage LocationofMarriage DateofTermination DivorcedorWidow(er)

Husband Wife ToWhom DateofMarriage LocationofMarriage DateofTermination DivorcedorWidow(er)

1. Doyouhavechildrenwithsomeoneotherthanyourcurrentspouse?a. Whataretheirnamesandages?

b. Wheredotheyreside?

2. Ifapplicable,whydidyougetmarriedtoyourpreviouspartner(s),andwhatledtothedivorce?Husband:Wife:

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ADDITIONALQUESTIONS:3. Doeseitherthehusbandorwifesmoke?�Husband�Wife

4. Doeseitherthehusbandorwifedrink?�Husband�WifeExplainhowmuchandonwhatoccasion:

5. Doeseitherthehusbandorwifeuseillegalorprescriptiondrugs?�Husband�Wife(Youmaybeaskedforarandomdrugtest)Pleasegivedetailsastowho,when,what,why?

6. Haveyoueverhadanaddictiontopornography? �Husband�WifeIfso,didyoureceivehelp,pleaseexplain.

7. Haseitherthehusbandorwifebeencharged(butnotconvicted)ofafelony?☐Husband☐WifeWho,What,When,Why?

8. Haseitherhusbandorwifebeenarrestedorincarcerated?�Husband�WifeWho,What,When,Why?

9. Hasanyoneinthehouseholdbeenseenbyamentalhealthprofessionalforcounseling/therapy?�Husband�Wife�Child:__________�OtherfulltimehouseholdmemberDatesofservice:NameandAddressofMentalHealthProfessional*:*Pleaseprovideastatementfromyourmentalhealthprofessionalthatincludesdatesofservice,theresolutionoftheissue,andanevaluationofthefamily’semotionalpreparednesstocareforachildwhohasexperiencedtrauma.

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ReferencesListthenamesandaddressesofFIVEreferencesasfollows;

1. Pastoral

a. Name:

b. Address:

c. City,State,Zip:

d. Phone:

2. Non-Relative(fromyourcommunity-example:schoolpersonnel,neighbor,etcetera)

a. Name:

b. Address:

c. City,State,Zip:

d. Phone:

3. Non-Relative

a. Name:

b. Address:

c. City,State,Zip:

d. Phone:

4. Non-Relative

a. Name:

b. Address:

c. City,State,Zip:

d. Phone:

5. Relative

a. Name:

b. Address:

c. City,State,Zip:

d. Phone:

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ChildPreferenceINDICATE YOUR PREFERENCES:Age(s) Gender Ethnicity Sibling (Group of)

☐0 to 3yrs. ■

☐4 to 8yrs. ■

☐ 9 to 12 yrs. ■

☐ 13 to 15 yrs. ■

☐ 16 to 18 yrs.

☐ Other .

☐ Male Only

☐ Female Only

☐ No Preference

☐Caucasian ■

☐Hispanic

☐ African/Amer ■

☐ Asian

☐ Native American ■

☐Other

☐ Bi-Racial

☐No Sibling Groups

☐2

☐ 3

☐ 4

☐ 5 or more

Twins: � Yes � NoAge Range of Siblings:

.

Listanyothersyouwouldconsiderthatarenotmentioned:

______________________________________________________________________________

______________________________________________________________________________

Comments:____________________________________________________________________

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A-----AcceptableWTD-WillingtoDiscussNA---NotAcceptable

LegalRiskLegalriskreferstoachildnotavailableforadoptionbecausehisparent’srightshavenotyetbeenterminatedorachildplacedinfostercarewiththeintentionofmovingtoanadoptiveplacement.

This preference list is a guide that helps you and the agency determine your strengths andassets inbecominga resource fora child-needingplacement. Someof theaboveconditionscannotbedetermineduntilachildbecomesolder.Thispreferencelistdoesnotguaranteethatachildplacedwithyourfamilywillnotdevelopsomeoftheconditionslistedonthisform.______________________________________ ____________________Foster/AdoptiveHusband Date______________________________________ ____________________Foster/AdoptiveWife Date

Child’sBirth&HealthHistory A WTD NA

Prematurity Apneaepisodes Historyofseizures Positivedrugscreendrugidentified Exposuretoalcoholduringpregnancy Mothersmokedduringpregnancy Mentalretardation Cerebralpalsy SpinaBifida Dietaryproblems Allergies HIVpositive

Correctable A WTD NA

Orthopediccondition Heartcondition Eyecondition Other

LegalRisk A WTD NA

LegalRisk

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We,_______________________________________________,declarethattheinformationonthisapplicationistrueandcorrect. WeunderstandthatanyerroneousinformationwouldbegroundsforLovingHoustonAdoptionAgencytodenyourapplicationordiscontinueanyfurtherprocessoftheplacementofachildintoourhome.

___________________________________________ _____________________

ProspectiveFather Date

__________________________________________ ______________________

ProspectiveMother Date

PleaseAttach:

! Apictureofhusbandandwife

! Apictureofyourchildren

! Picturesoftheoutsideofyourhome

Afamilypictureisacceptableaslongaseachfamilymemberisclearlydiscernable.