Child Abuse History Record Request for Private Adoption

Child Abuse History Record Request for Private Adoption
NOTE: This form must be submitted by the agency identified at the bottom of this page. The applicant may NOT SUBMIT THIS FORM DIRECTLY to the Department of Children & Families.

LIST ALL minor household members on this form. Do not include ANY adult household members or foster care children.
TO BE COMPLETED BY APPLICANT
(Please Print Clearly – Last Name, First, Middle)
Applicant: SSN
_ DOB

MonthDayYear
Date
Race
Sex
Prior Name(s)
Current Address
Dates at Address

MonthDayYear
Date
Previous Address
Dates at Address

MonthDayYear
Date
(Include city, state, and Zip Code)
Dates at Address (Include city, state, and Zip Code) By signing this form, I, as an applicant for adoption, authorize a search for reports of abuse, neglect or abandonment investigated in which my name appears and there were “verified findings” of maltreatment of a child(ren) and I am listed as the “Caregiver Responsible”. I further understand that the central abuse hotline search is only one part of the preliminary report to the court for adoption. I understand I will be given the opportunity to discuss the findings of the report(s This consent is valid solely for the requesting agency/facility listed below on this form. (Chapter 39, F.S.)
Signature of Applicant*

Clear
Date

MonthDayYear
Date
ALL ADULT (18 & UP) HOUSEHOLD MEMBERS MUST SUBMIT A SEPARATE REQUEST FORM

PLEASE LIST INFORMATION FOR ALL MINOR (17 & UNDER) HOUSEHOLD MEMBERS EXCEPT FOSTER CHILDREN. SSN DOB

Please use another request form for additional household members
TO BE COMPLETED BY REQUESTING AGENCY
Private Attorney

XXChild-Placing AgencyLCSW/LMCFACCCA (Florida Association of Children Child Caring Agencies)OtherOther
Facility/Agency Name: Address:

1098 N.W. BOCA RATON BLVD., BOCA RATON, FLORIDA 33432

Email: I understand it is a misdemeanor of the first degree for any agency to use or release abuse, neglect or abandonment information to others. The information is CONFIDENTIAL and may be used only for the purpose for which it was obtained.

Printed Name and Signature of Requesting Facility/Agency Representative
CHARLOTTE H. DANCIU

Clear
CHARLOTTE H. DANCIU

MonthDayYear
Date
Please return to DCF via email: Attention: Private Adoptions

email: hqw.bgs.adoptions@myflfamilies.com
Should be Empty: