• CAC Paperwork Prep Questionnaire

    CAC Paperwork Prep Questionnaire

    Please remember that the answers provided will be transferred exactly as written to agency applications. In some cases, non-identifying portions will be shared with expectant/birth families. Several fields have a limit on the number of characters you can use in your answers, due to the size needed to complete the agency applications.

  • Important: This form has a "Save" button feature at the bottom of the page that allows you to save your progress and finish later. Drafts are only saved for two months.

  • CAC Consultant*

  • FAMILY / HOME INFORMATION

  • Relationship Status*
  • Area of Country Where You Reside*
  • Would you consider the immediate area that you live in to be:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Marriage
     / /
  • 0/100
  • Do you own, rent, or lease your home?
  • 0/60
  • Do you have a pool?
  • Does it have a fence?
  • 0/90
  • Do you have any home alarms?
  • 0/90
  • Do you own or possess any firearms?
  • 0/90
  • 0/70
  • 0/70
  • Are you a member of your church?
  • Do you participate in church activities?
  • 0/175
  • 0/175
  • Have you participated/attended counseling or therapy, either individually or as a couple (if applicable)?
  • 0/200

  • PETS

  • Do you have any pets?
  • Are they currently vaccinated?
  • Are they licensed?

  • EMERGENCY CONTACTS

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • ADOPTION QUESTIONS

  • Have you ever applied to adopt a child from another source?
  • Do you know anyone well who is adopted?
  • Are you able to have biological children?
  • 0/150
  • 0/150
  • 0/45
  • 0/200
  • 0/150
  • 0/150
  • 0/100
  • 0/100
  • 0/75
  • 0/75
  • 0/75

  • ADOPTION QUESTIONS (continued)

  • 0/75
  • 0/75
  • 0/100
  • 0/75
  • 0/75
  • 0/75
  • 0/75
  • 0/75
  • 0/75
  • 0/80
  • 0/80
  • 0/80
  • 0/80
  • 0/80
  • Do you want your profile available on the agency's/attorney's website?

  • BACKGROUND CLEARANCES

    For applicants NOT residing in Arizona, please provide the dates of clearances for all household members 18 years and older.
  • ADOPTIVE FATHER - FBI
     / /
  • ADOPTIVE MOTHER - FBI
     / /
  • ADOPTIVE FATHER - State
     / /
  • ADOPTIVE MOTHER - State
     / /
  • ADOPTIVE FATHER - Child Abuse Registry
     / /
  • ADOPTIVE MOTHER - Child Abuse Registry
     / /

  • HOME STUDY

    If you don't have a completed home study or background checks yet, you can skip these questions.
  • Format: (000) 000-0000.
  • Date Completed
     / /
  • Have you ever been rejected or received an unfavorable home study?
  • 0/100

  • QUESTIONS FOR ADOPTIVE FATHER

  • Date of Birth
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Health
  • 0/75
  • Have you had any recent hospitalizations?
  • 0/75
  • Are you currently taking any medications?
  • 0/75
  • Any serious chronic illness, including mental or psychiatric treatment?
  • 0/100
  • Do you smoke?
  • Would you be willing to undergo an HIV test?
  • Do you consume alcohol?
  • Format: (000) 000-0000.
  • 0/75
  • Have you ever served in the military?
  • Do you have a 401(k)?

  • ADOPTIVE FATHER (continued)

  • 0/75
  • 0/75
  • 0/75
  • 0/75
  • 0/100
  • 0/75
  • 0/75
  • 0/75
  • 0/125
  • 0/125
  • 0/75

  • Your Father

  • First and Last Name:
    Birthdate: Pick a Date   
    Address:              
    Email:  
    Phone:    
    General Health:      
    Occupation:      
    If deceased, please indicate age at death and cause of death:      

  • Your Mother

  • First and Last Name:
    Birthdate: Pick a Date   
    Address:              
    Email:  
    Phone:    
    General Health:      
    Occupation:      
    If deceased, please indicate age at death and cause of death:      

  • Have you had any previous marriages?
  • Date of Previous Marriage
     / /
  • Date of Divorce
     / /

  • Siblings

  • 0/150
  • 0/150
  • 0/150

  • Addresses for Past Five Years

  • Have you ever been arrested? (Include any traffic offenses such as DUI and suspended license)
  • 0/60
  • Have you ever had a felony or misdemeanor conviction?
  • 0/60
  • Have you even been named in an abuse incident?
  • 0/60
  • Have you ever been treated for substance abuse?
  • 0/60
  • Have you ever been involved in a domestic violence situation?
  • 0/60
  • If you answered YES to any of the above questions, were any of the incidents in Florida?
  • 0/40

  • If you answered YES to any of the questions regarding criminal history, please provide a written description of the event, giving as much detail as possible, and include the specific information listed below (use a separate sheet of paper per event). *Document MUST be signed in the presence of a notary.*

    Your name | Date of event | City, state, and county where the event occurred | Detailed description of the event | Date of disposition, the disposition, and result of rehabilitation (time served, fines paid, etc.) | Effect of the event on you, your family, your life | Your signature and printed name

  • QUESTIONS FOR ADOPTIVE MOTHER

  • Date of Birth
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Health
  • 0/75
  • Have you had any recent hospitalizations?
  • 0/75
  • Are you currently taking any medications?
  • 0/75
  • Any serious chronic illness, including mental or psychiatric treatment?
  • 0/75
  • Do you smoke?
  • Would you be willing to undergo an HIV test?
  • Do you consume alcohol?
  • Format: (000) 000-0000.
  • 0/75
  • Have you ever served in the military?
  • Do you have a 401(k)?

  • QUESTIONS FOR ADOPTIVE MOTHER (continued)

  • 0/75
  • 0/75
  • 0/75
  • 0/100
  • 0/75
  • 0/75
  • 0/75
  • 0/125
  • 0/125
  • 0/75

  • Your Father

  • First and Last Name:
    Birthdate: Pick a Date   
    Address:              
    Email:  
    Phone:    
    General Health:      
    Occupation:      
    If deceased, please indicate age at death and cause of death:      

  • Your Mother

  • First and Last Name:
    Birthdate: Pick a Date   
    Address:              
    Email:  
    Phone:    
    General Health:      
    Occupation:      
    If deceased, please indicate age at death and cause of death:      

  • Have you had any previous marriages?
  • Date of Previous Marriage
     / /
  • Date of Divorce
     / /

  • Siblings

  • 0/150
  • 0/150

  • Addresses for Past Five Years

  • Have you ever been arrested? (Include any traffic offenses such as DUI and suspended license)
  • 0/60
  • Have you ever had a felony or misdemeanor conviction?
  • 0/60
  • Have you even been named in an abuse incident?
  • 0/60
  • Have you ever been treated for substance abuse?
  • 0/60
  • Have you ever been involved in a domestic violence situation?
  • 0/60
  • If you answered YES to any of the above questions, were any of the incidents in Florida?
  • 0/60

  • If you answered YES to any of the questions regarding criminal history, please provide a written description of the event, giving as much detail as possible, and include the specific information listed below (use a separate sheet of paper per event). *Document MUST be signed in the presence of a notary.*

    Your name | Date of event | City, state, and county where the event occurred | Detailed description of the event | Date of disposition, the disposition, and result of rehabilitation (time served, fines paid, etc.) | Effect of the event on you, your family, your life | Your signature and printed name

  • CHILDREN

  • Do you currently have children in the home?
  • If so, are they immunized?
  • 0/60
  • Do all of your children live with you?
  • 0/100
  • 0/50
  • If applicable, have you ever been past due on any court ordered installment of child support?

  • Please complete the following information about your children:

  • Does anyone in your household have a record with the FL Dept of Law Enforcement or an abuse registry record in FL?
  • Does anyone in your household have an arrest or criminal record with any state, or abuse registry record any state, or in another country?

  • If you answered YES to any of the questions regarding criminal history, please provide a written description of the event, giving as much detail as possible, and include the specific information listed below (use a separate sheet of paper per event). *Document MUST be signed in the presence of a notary.*

    Your name | Date of event | City, state, and county where the event occurred | Detailed description of the event | Date of disposition, the disposition, and result of rehabilitation (time served, fines paid, etc.) | Effect of the event on you, your family, your life | Your signature and printed name

  • FINANCIAL INFORMATION

  • Do you have a will?
  • You will need to identify a guardian for your child. Do you have an identified person?

  • HEALTH INSURANCE

  • Format: (000) 000-0000.
  • When does your insurance begin coverage of the adopted child?

  • LIFE INSURANCE

  • ADOPTION BUDGET

  • Can you verify these funds?
  • Do you plan to apply for a subsidy or grant?
  • Are you prepared to cover all birth mom's and baby's medical costs that are NOT covered by Medicaid/insurance?

  • CHILD PREFERENCES

  • Ethnicity Preference
  • Gender Preference
  • Which ages would you accept?
  • Are you open to twins?
  • Are you open to triplets?
  • Are you open to sibling groups?
  • If yes:
  • Are you open to premature birth?
  • If yes, select all that apply:
  • Birth Father Risk Tolerance
  • Birth Father Situations
  • Health issues/situations you would be willing to accept:
    Rows
  • 0/125
  • 0/125

  • Situation / Condition Preferences

  • Use the checkboxes in each dropdown field to indicate your consideration for the following:
    Rows

  • Prenatal Exposures

  • Please consider the following and check all you are willing to accept:
    Rows
  • 0/225

  • CONTACT WITH BIRTH PARENTS

  • What kind of placement are you interested in?
  • 0/40
  • Type of Contact
    Rows

  • REFERENCES

    Provide information for five (5) non-relative references.
  • Reference #1
  • Reference #2
  • Reference #3
  • Reference #4
  • Reference #5

  • APPLYING WITH AGENCIES

  • Should be Empty: