LIFESTYLE
Describe lifestyle
Hobbies. Interests, talents, etc.
How does couple spend time together
Shared interest
How do they spend time alone
EDUCATION AND EMPLOYMENT
Summarize Job history
Job satisfaction
Job security
Career goals
MILITARY HISTORY
Branch of military served
How long
When
Where
Honorable Discharge?
HOUSE AND NEIGHBORHOOD
Brief Description
1. Age of house
2. How long have they lived there
3. Own or rent
4, History of residences as married couple
assess changes of residence over time
5. Number of levels
6. Number of rooms
7 Safety check:
a) number of smoke detectors, are they
operational, one on each level
b) fire extinguishers in all cooking areas
are they operational
c) are structural components of the home in
optimal working condition
d) what repairs have to be made
e) if water is obtained from a well, need a
form from a company authorized to check
levels. Statement must be attached
8. Any pets
9. Description of neighborhood
10. Are there places for recreation
11. School District:
Where do parents plan to send their children
to school (public, private, parochial)
*Naturally, intentions can change
FINANCES
INCOME
ASSETS
INVESTMENTS
SAVINGS
MOST RECENT 1040 FORM
DEBITS
DEBTS
OUTSTANDING LOANS
PAYMENTS
MANAGEMENT OF FINANCES
MANAGEMENT
MONEY OF PHILOSOPHY DO BOTH AGREE ON COMMON
APPROACH TO MONEY MANAGEMENT
DO THEY CONSIDER THEMSELVES AS THRIFTY,
CONSERVATIVE, LAVISH, FLASHY, ETC.
HEALTH INSURANCE
Type of coverage
LIFE INSURANCE
Face value of policy(s)
REFERENCES
A minimum of three reference letters must be
submitted to ( AGENCY ) record. The
references must include the following:
a) Three (3) personal references from persons
unrelated to the applicant
* One of these references must know the
applicant for at least five years
b) One reference from a current neighbor of
the applicant
c) One reference by the applicant's employer
HEALTH
State that medical reports have been
submitted to the record.
Discuss any problems that may limit their
capabilities and or shorten their life
expectancy
CRIMINAL HISTORY INVESTIGATION
All must obtain a statement from state police
stating that they have no criminal record.
CHILD ABUSE INVESTIGATION
A child abuse report from D.P.W. ( health and
human services ) must be submitted
HOME VISIT OUTLINE
Name
Age:
Date of birth:
Physical characteristics:
Personality characteristics:
Cultural background:
Social background:
Name Female:
Same as Above
Children ( note it at home )
Same as Above
Description of Neighborhood
COMMUNITY
HOME
Total rooms
L/R
D/R
Kitchen
Bedrooms
Baths
Other rooms
SMOKE DETECTORS- #
FIRE EXTINGUISHERS-#
SOCIAL PROGRAMS FOR CHILDREN
EDUCATIONAL GOALS FOR CHILD
OTHER INFORMATION
Attitude toward adopting a child
Attitude toward race and religion
Attitude toward biological parent(s)
Attitude toward child in relation to
biological family
Type of child being considered:
Domestic adoption
Foreign adoption
Race of child
Religion of child
Health related issues
Emotional issues
Attitude of extended family toward the
adoption
Attitude of friends toward the adoption
What seminars, workshops or meetings have
been attended pertaining to adoptive related
issues.
What support groups will be used if
necessary: inc: Therapist, Psychologist,
School, Extended programs
How will you integrate the child into
the following:
a) Household
b) Neighborhood
c) Extended Family
d) School
