Prospective Adoption Parent(s) Form

Prospective Adoption Parent(s) Questionnaire

*Please Note: All fields are required in order for application to be complete.
If a question does not apply to you, please mark “N/A”.*

Full Name (1)*
First Middle Last
Full Name (2)*
First Middle Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country

How long have you resided at this address?*

Y	M

County of current residence?*
Have you resided in the State of Kentucky for at least the past five (5) years?*
- Yes
- No
Please list any State, other than Kentucky, that adoptive parent(s) have resided in the past ten (10) years*
Phone Number (1)*
Email Address (1)*
Phone Number (2)*
Email Address (2)*
Date of Birth (1)*
MM slash DD slash YYYY
Race/Nationality (1)*
Date of Birth (2)*
MM slash DD slash YYYY
Race/Nationality (2)*
Social Security # (1)*
Social Security # (2)*
Are you legally married to each other?*
- Yes
- No
Date of marriage?*
MM slash DD slash YYYY
Location of marriage?*
Legally divorced (1)?*
- Yes
- No
Legally divorced (2)?*
- Yes
- No
(You will have to obtain certified copies of your divorce decrees for your Home Study)
Emergency Contact*
Relationship*
Phone Number*
Highest Educational Level Obtained (1)*
College Degree (1)*
Highest Educational Level Obtained (2)*
College Degree (2)*
Occupation (1)*
Occupation (2)*
Employer (1)*
Employer (2)*
Length of Employment (1)*
Length of Employment (2)*
Work Phone (1)*
Work Phone (2)*
Annual Income (1)*
Annual Income (2)*
How many children do you have, including any adult children?*

Please list the names/ Date of Birth/ ages of ALL children living in you home*

Name	Date of Birth	Age

(Click the + icon to add more row)

Please list the full names/ Date of Birth/ Age/ Phone Number/ Address of ALL grown children living away from home*

Full Name	Date of Birth	Age	Phone Number	Address

(Click the + icon to add more row)

Please list the full names/ Date of Birth/ Age of ALL other adult person living in your home*

Full Name	Date of Birth	Age	Relationship to you

(Click the + icon to add more row)
Have you adopted a child before?*
- Yes
- No
If yes, How many times?
Is it Domestic or International?
- Domestic
- International
- Both
- N/A
Name of agency? Location?
Do you have any children in your home that are not your biological or adopted child?*
- Yes
- No
Have you ever completed a Home Study/Investigation?*
- Yes
- No
Are you prepared to initiate the Home Study immediately?*
- Yes
- No
Are you prepared to pay the one-time, upfront, non-refundable agency fee of $6000.00 to become an active client with Unexpected Blessings Adoption? (This fee includes the administrative cost associated with the Home Study completion, if you reside in the State of KY.)*
- Yes
- No
Are you prepared to pay any birth parent expenses, i.e. living expenses, medical expenses, birth expenses, clothing expenses, travel expenses, etc.?*
- Yes
- No
If Yes, what is your budget for birth parent expenses? (Please note that birth expenses are due if/when needed, and every situation will vary.)
Are you prepared to pay legal fees associated with the adoption of a child? Legal fees will include up to four (4) attorneys for: prospective adoptive parent(s): birth mother; birth father (if involved); and a guardian ad litem for the child (this attorney is appointed by the judge). The legal fees will be due at time each attorney is needed. Estimated legal fees for an in-state KY adoption will likely range between $3500-$4500.*
- Yes
- No
In the State of Kentucky, open adoption is not a legally binding option. If the birth parent(s) is/are in agreement, are you interested in having limited contact with the birth parent(s) after the adoption is final, as agreed upon by all involved parties? (This is usually limited to letters, cards and pictures.)*
- Yes
- No
When answering the following questions, please be open and honest, as the information will be used in conjunction with the background checks and other supporting documentation that is required for the potential approval of ANYONE seeking to adopt a child in the State of Kentucky.
Have either of you ever been arrested, investigated or convicted for violation of any law or are you currently under charges for any violation?*
- Yes
- No
If yes, please explain
Have either of you ever been diagnosed with mental illness or addiction?*
- Yes
- No
If yes, please give diagnosis/addiction and treatment
Have either of you ever received therapy and/or counseling?*
- Yes
- No
If yes, please give reason and dates received
Have either of you ever been diagnosed with a chronic or terminal medical illness/disease that could effect your ability to raise a child?*
- Yes
- No
If yes, please give reason and dates received
When answering the below questions, please be open and honest to your true feelings and beliefs, as the information will be used to assist in matching you with the best situation to meet your wants and needs as adoptive parents, the wants and needs of the birth parent(s), and the needs of the child.
Do you have any religious or spiritual affiliation?*
- Yes
- No
If yes, please specify your affiliation
Do you have any preference as to the religious or spiritual affiliation of the birth parent(s)?*
- Yes
- No
If yes, please specify your preference
Do you have any preference as to the race/nationality/ethnicity of the birth parent(s)?*
- Yes
- No
If yes, please specify your preference
Do you want to have any contact with the birth mother during her pregnancy and/or during the birth of the child?*
- Yes
- No
Are prepared to accept a child of either gender?*
- Yes
- No
If no, what is your preferred gender?
- Male
- Female
Are you prepared to accept children from a multiple birth, i.e. twins, triplets?*
- Yes
- No
If yes, please specify your limit, i.e. twins, etc.
Are you open to the possibility of accepting children from a sibling group?*
- Yes
- No
Are you willing to accept a child who is known to have birth defects, physical and/or mental?*
- Yes
- No
Are you willing to accept a child of any age?*
- Yes
- No
if no, please specify your age limit
Consent
I/We undestand and agree
The above information is true and complete to the best of our knowledge. I/We understand that falsification of information and/or misrepresentation of facts will result in the rejection of your application. I/We also understand and agree to Unexpected Blessigns Adoption, LLC using the information provided on this form to initiate state and/or federal background checks as indicated by the responses provided on this form.

I/We understand that every potential adoption situation is special and unique and that there is never a guarantee that a successful adoption will take place.
Prospective Adoptive Parent (1)*
Signature*
Date*
MM slash DD slash YYYY
Prospective Adoptive Parent (2)*
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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