Vision of Hope Ministries Adoptive Family Background
Vision of Hope Ministries Adoptive Family Background Form Date Submitted: _______________ Along with this form, please include: _____ 1-3 page “Dear birthmother” letter describing your family, your reasons for wanting to adopt, your level of interest regarding open adoptions, and any other specifics you feel would be pertinent for a birthmother to know about your family. Please do not include your last name, contact information, or personal identifying information in this letter. _____ Photograph of your family (5x7 or smaller) _____ Letter of recommendation from your pastor _____ Contact information for 3-5 personal references with whom you are well acquainted
Contact Information Name: __________________________________________________________________ Home Address: ___________________________________________________________ ________________________________________________________________________ Primary Phone Number: ____________________________________________________ Secondary Phone Number(s): ________________________________________________ E-mail address: ___________________________________________________________
Wife’s Background Information: Name: __________________________________________________________________ First Middle Last Date of birth: ________________ Race: _________________ Current Age: ____________ Height: _____________________________ Normal Weight: ______________________ Eye Color: _____________ Hair Color: _______________ Complexion: _____________
Education: High School _____________________________________________________________ Last grade completed __________________ Year ____________ Grade Avg _________ College _________________________________________________________________ Major _____________________________ Minor ______________________________
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8/25/2016
Spiritual History: Please describe your present relationship with God: _______________________________ _________________________________________________________________________ _________________________________________________________________________ How long of have had a relationship with God? __________________________________ What is your belief concerning salvation? _______________________________________ ________________________________________________________________________ ________________________________________________________________________ Where do you attend church? ________________________________________________ What ways are you involved in your church? ___________________________________ _______________________________________________________________________ Pastor’s Name and phone number: ____________________________________________
Personal Information List any talents you may have: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ Hobbies and interests: ______________________________________________________ ________________________________________________________________________ Please describe your personality: _____________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you utilized counseling services, currently or in the past? If yes, what kind of services? ________________________________________________________________________ ________________________________________________________________________ Have you ever committed or been convicted of a crime? If so, please explain. ________________________________________________________________________ _________________________________________________________________________
Work History: Current Employer: ________________________________________________________ Current Position: _________________________________________________________ How long have you held that position? ________________________________________ 2
8/25/2016
What are your employment plans for the next 5-10 years? _________________________ ________________________________________________________________________ ________________________________________________________________________ Wife’s Family History: (Please be thorough) Health History: Illnesses: ________________________________________________________________ ________________________________________________________________________ Allergies: _______________________________________________________________ ________________________________________________________________________ Medical Conditions: _______________________________________________________ ________________________________________________________________________ Do you wear Glasses ____________ Contacts _____________ Braces ______________
Family Culture: Wife’s family’s cultural heritage is: _________________________________ ________________________________________________________________________ Description of wife’s family (structure, traditions, extended family habits): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Family Structure: _____ I grew up in a traditional nuclear family (one mother, one father) _____ I grew up in a blended family. If so please describe below. _____ I grew up in another kind of family. If so please describe below. _____ I grew up with siblings. # of sisters ___________ # of brothers _____________ _____ I grew up with step-siblings. If so please describe below. Description of family relationships: ___________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
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8/25/2016
________________________________________________________________________ ________________________________________________________________________
Husband’s Background Information: Name: __________________________________________________________________ First
Middle
Last
Date of birth: ________________ Race: _________________ Current Age: ____________ Height: _____________________________ Normal Weight: ______________________ Eye Color: _____________ Hair Color: _______________ Complexion: _____________
Education: High School _____________________________________________________________ Last grade completed __________________ Year ____________ Grade Avg _________ College _________________________________________________________________ Major _____________________________ Minor ______________________________
Spiritual History: Please describe your present relationship with God: _______________________________ _________________________________________________________________________ _________________________________________________________________________ How long of have had a relationship with God? __________________________________ What is your belief concerning salvation? _______________________________________ _________________________________________________________________________ _________________________________________________________________________ Where do you attend church? ________________________________________________ What ways are you involved in your church? __________________________________ _______________________________________________________________________ Pastor’s Name and phone number: ____________________________________________
Personal Information List any talents you may have: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ Hobbies and interests:______________________________________________________ 4 8/25/2016
________________________________________________________________________ Please describe your personality:_____________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you utilized counseling services, currently or in the past? If yes, what kind of services? ________________________________________________________________________ ________________________________________________________________________ Have you ever committed or been convicted of a crime? If so, please explain. ________________________________________________________________________ _________________________________________________________________________
Work History: Current Employer: ________________________________________________________ Current Position: _________________________________________________________ How long have you held that position? ________________________________________ What are your employment plans for the next 5-10 years? _________________________ ________________________________________________________________________ ________________________________________________________________________ Husband’s Family History: (Please be thorough) Health History: Illnesses: ________________________________________________________________ ________________________________________________________________________ Allergies: _______________________________________________________________ ________________________________________________________________________ Medical Conditions: _______________________________________________________ ________________________________________________________________________ Do you wear Glasses ____________ Contacts _____________ Braces ______________ Husband’s Family Culture: Husband’s family’s cultural heritage is: ________________________________________ ________________________________________________________________________ Description of husband’s family (structure, traditions, extended family habits): ________________________________________________________________________ 5 8/25/2016
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Family Structure: _____ I grew up in a traditional nuclear family (one mother, one father) _____ I grew up in a blended family. If so please describe below. _____ I grew up in another kind of family. If so please describe below. _____ I grew up with siblings. # of sisters ___________ # of brothers _____________ _____ I grew up with step-siblings. If so please describe below. Description of family relationships: ___________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Current Family Structure and General Information What year did you get married? ___________________________________________ Has either spouse been married previously? ___________________________________ Please describe your marriage: ______________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Please list if you currently have children: Daughters and their DOB: _________________________________________________ _______________________________________________________________________ Sons and their DOB: ______________________________________________________ _______________________________________________________________________ Are your children biological or adopted? ________________________________________ Do you hope to add to your family after this adoption? _____________________________ What does your family enjoy doing together? ____________________________________ _______________________________________________________________________ 6
8/25/2016
_______________________________________________________________________ Does anyone else live in your home besides you, your spouse, and your children? _____ ________________________________________________________________________
Have either of you or any other household member, including children residing in the home, ever had any addiction to a substance now or in the past? If yes, please explain. ________________________________________________________________________ ________________________________________________________________________ Have either of you or any other household member, including children residing in the home, ever been investigated, accused of, committed, or have been convicted of child abuse? If yes, please explain. ___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Family’s Decision to Adopt Please describe why you are interested in adopting: ______________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Please describe your plans for any children that you adopt (caregivers, education, church, etc.): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ How do you think your extended family will react to an adoption? __________________ ________________________________________________________________________ ________________________________________________________________________ Do you foresee any problems with an adoption? ________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7
8/25/2016
What are your preferences or thoughts regarding an open or semi-open adoption? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you consider adopting a toddler, older child or sibling group? ________________ ________________________________________________________________________ What are your thoughts on adopting a child with special needs or prenatal exposure to drugs or alcohol? _______________________________________________________________ ________________________________________________________________________
Is there any information you think is important for the birthparents to know about you, your family, your situation, or your desire to adopt? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
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8/25/2016
Contact Information Name: __________________________________________________________________ Home Address: ___________________________________________________________ ________________________________________________________________________ Primary Phone Number: ____________________________________________________ Secondary Phone Number(s): ________________________________________________ E-mail address: ___________________________________________________________
Wife’s Background Information: Name: __________________________________________________________________ First Middle Last Date of birth: ________________ Race: _________________ Current Age: ____________ Height: _____________________________ Normal Weight: ______________________ Eye Color: _____________ Hair Color: _______________ Complexion: _____________
Education: High School _____________________________________________________________ Last grade completed __________________ Year ____________ Grade Avg _________ College _________________________________________________________________ Major _____________________________ Minor ______________________________
1
8/25/2016
Spiritual History: Please describe your present relationship with God: _______________________________ _________________________________________________________________________ _________________________________________________________________________ How long of have had a relationship with God? __________________________________ What is your belief concerning salvation? _______________________________________ ________________________________________________________________________ ________________________________________________________________________ Where do you attend church? ________________________________________________ What ways are you involved in your church? ___________________________________ _______________________________________________________________________ Pastor’s Name and phone number: ____________________________________________
Personal Information List any talents you may have: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ Hobbies and interests: ______________________________________________________ ________________________________________________________________________ Please describe your personality: _____________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you utilized counseling services, currently or in the past? If yes, what kind of services? ________________________________________________________________________ ________________________________________________________________________ Have you ever committed or been convicted of a crime? If so, please explain. ________________________________________________________________________ _________________________________________________________________________
Work History: Current Employer: ________________________________________________________ Current Position: _________________________________________________________ How long have you held that position? ________________________________________ 2
8/25/2016
What are your employment plans for the next 5-10 years? _________________________ ________________________________________________________________________ ________________________________________________________________________ Wife’s Family History: (Please be thorough) Health History: Illnesses: ________________________________________________________________ ________________________________________________________________________ Allergies: _______________________________________________________________ ________________________________________________________________________ Medical Conditions: _______________________________________________________ ________________________________________________________________________ Do you wear Glasses ____________ Contacts _____________ Braces ______________
Family Culture: Wife’s family’s cultural heritage is: _________________________________ ________________________________________________________________________ Description of wife’s family (structure, traditions, extended family habits): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Family Structure: _____ I grew up in a traditional nuclear family (one mother, one father) _____ I grew up in a blended family. If so please describe below. _____ I grew up in another kind of family. If so please describe below. _____ I grew up with siblings. # of sisters ___________ # of brothers _____________ _____ I grew up with step-siblings. If so please describe below. Description of family relationships: ___________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
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8/25/2016
________________________________________________________________________ ________________________________________________________________________
Husband’s Background Information: Name: __________________________________________________________________ First
Middle
Last
Date of birth: ________________ Race: _________________ Current Age: ____________ Height: _____________________________ Normal Weight: ______________________ Eye Color: _____________ Hair Color: _______________ Complexion: _____________
Education: High School _____________________________________________________________ Last grade completed __________________ Year ____________ Grade Avg _________ College _________________________________________________________________ Major _____________________________ Minor ______________________________
Spiritual History: Please describe your present relationship with God: _______________________________ _________________________________________________________________________ _________________________________________________________________________ How long of have had a relationship with God? __________________________________ What is your belief concerning salvation? _______________________________________ _________________________________________________________________________ _________________________________________________________________________ Where do you attend church? ________________________________________________ What ways are you involved in your church? __________________________________ _______________________________________________________________________ Pastor’s Name and phone number: ____________________________________________
Personal Information List any talents you may have: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ Hobbies and interests:______________________________________________________ 4 8/25/2016
________________________________________________________________________ Please describe your personality:_____________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you utilized counseling services, currently or in the past? If yes, what kind of services? ________________________________________________________________________ ________________________________________________________________________ Have you ever committed or been convicted of a crime? If so, please explain. ________________________________________________________________________ _________________________________________________________________________
Work History: Current Employer: ________________________________________________________ Current Position: _________________________________________________________ How long have you held that position? ________________________________________ What are your employment plans for the next 5-10 years? _________________________ ________________________________________________________________________ ________________________________________________________________________ Husband’s Family History: (Please be thorough) Health History: Illnesses: ________________________________________________________________ ________________________________________________________________________ Allergies: _______________________________________________________________ ________________________________________________________________________ Medical Conditions: _______________________________________________________ ________________________________________________________________________ Do you wear Glasses ____________ Contacts _____________ Braces ______________ Husband’s Family Culture: Husband’s family’s cultural heritage is: ________________________________________ ________________________________________________________________________ Description of husband’s family (structure, traditions, extended family habits): ________________________________________________________________________ 5 8/25/2016
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Family Structure: _____ I grew up in a traditional nuclear family (one mother, one father) _____ I grew up in a blended family. If so please describe below. _____ I grew up in another kind of family. If so please describe below. _____ I grew up with siblings. # of sisters ___________ # of brothers _____________ _____ I grew up with step-siblings. If so please describe below. Description of family relationships: ___________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Current Family Structure and General Information What year did you get married? ___________________________________________ Has either spouse been married previously? ___________________________________ Please describe your marriage: ______________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Please list if you currently have children: Daughters and their DOB: _________________________________________________ _______________________________________________________________________ Sons and their DOB: ______________________________________________________ _______________________________________________________________________ Are your children biological or adopted? ________________________________________ Do you hope to add to your family after this adoption? _____________________________ What does your family enjoy doing together? ____________________________________ _______________________________________________________________________ 6
8/25/2016
_______________________________________________________________________ Does anyone else live in your home besides you, your spouse, and your children? _____ ________________________________________________________________________
Have either of you or any other household member, including children residing in the home, ever had any addiction to a substance now or in the past? If yes, please explain. ________________________________________________________________________ ________________________________________________________________________ Have either of you or any other household member, including children residing in the home, ever been investigated, accused of, committed, or have been convicted of child abuse? If yes, please explain. ___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Family’s Decision to Adopt Please describe why you are interested in adopting: ______________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Please describe your plans for any children that you adopt (caregivers, education, church, etc.): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ How do you think your extended family will react to an adoption? __________________ ________________________________________________________________________ ________________________________________________________________________ Do you foresee any problems with an adoption? ________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7
8/25/2016
What are your preferences or thoughts regarding an open or semi-open adoption? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you consider adopting a toddler, older child or sibling group? ________________ ________________________________________________________________________ What are your thoughts on adopting a child with special needs or prenatal exposure to drugs or alcohol? _______________________________________________________________ ________________________________________________________________________
Is there any information you think is important for the birthparents to know about you, your family, your situation, or your desire to adopt? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
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8/25/2016
