• 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.

  • (Please Print Clearly – Last Name, First, Middle)

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  • (Include city, state, and Zip Code)

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  • 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.)

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

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  • Please use another request form for additional household members

  • TO BE COMPLETED BY REQUESTING AGENCY


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  • Printed Name and Signature of Requesting Facility/Agency Representative

    Please return to DCF via email: Attention: Private Adoptions

    email: hqw.bgs.adoptions@myflfamilies.com

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