Adoptive Family Readiness Survey
Applicant
*
First Name
Last Name
Co-Applicant (If applicable)
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Primary Email
*
example@example.com
How did you hear about our agency?
*
Family Ethnicity
*
African American
Asian
Caucasian
Hispanic
Native American
Mixed
Other
If mixed or other please specify.
What programs are you interested in? Select all that may apply.
*
Domestic
International
Homestudy
Other
Do you have a completed home study?
*
Yes
No
In progress
I would like Premier Adoption Agency to conduct one for me. (Only if residing in the states of Utah, Nevada, and Arizona.)
Do you have a profile book complete?
*
Yes
No
In progress
Preferences
Please keep in mind, the more open you are, the more likely you are of being chosen. You are permitted to change your preferences at any point during your adoption journey.
Do you have a preferred gender of the adoptive child?
*
Yes
No
If yes, please specify
Are you specific about the ethnicity of the adoptive child?
*
Yes
No
If yes, please specify
How open are you to prenatal alcohol exposure? Please mark all that apply.
*
1st Trimester
2nd Trimester
3rd Trimester
None
Please explain.
How open are you to prenatal drug exposure? Please mark all that apply.
*
1st Trimester
2nd Trimester
3rd Trimester
None
Depends on the type of drug.
Please explain.
*
Are you open to a situation with a history of family mental illness?
*
Yes
No
Depends
Please elaborate.
*
After placement are you open to communicating with the birth family via: Please mark all that apply.
*
Mailed Pictures and Letters Through Agency
Phone Calls/Texts
Social Media
Email
Unsupervised Visits
None
Are you open to paying for birth mother expenses?
*
Yes
No
Unsure
If yes, what is the maximum amount you are open to?
*
Minimum $5,000
Please provide any additional information that will help us understand your preferences for adoption.
Submit
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