Child Abuse History Record Request

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:

Month Day Year
Date
Race:
Sex:
Prior Name(s):
(Include city, state, and Zip Code)
Dates at Address

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dates at Previous Address

Month Day Year
Date
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

Month Day Year
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

Last Name First Name Middle Initial

DOB-

Race

Sex

SS#-

Please use another request form for additional household members
TO BE COMPLETED BY REQUESTING AGENCY
Reason for Record Search:

Private Attorney Child-Placing Agency LCSW/LMC FACCCA (Florida Association of Children Child Caring Agencies) Other
Phone:
(561) 330-6700
Address:
09505331Z
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.

Clear
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.

Month Day Year
Date
Printed Name and Signature of Requesting Facility/Agency Representative

Please return to DCF via email: Attention: Private Adoptions

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

Child Abuse History Record Request for Private Adoption

TO BE COMPLETED BY REQUESTING AGENCY