Adoption PERSONAL HISTORY QUESTIONNAIRE

PERSONAL HISTORY QUESTIONNAIRE

(Please complete in its entirety. For all household members over the age of 18)
North Texas Family Services Lauren Gordon, LCSW

Mailing address: 8301 Lakeview Parkway Suite 111-131, Rowlett TX 75088

945-354-3115
Personal Information:

This form may be used jointly for adoptive parents.
Adoptive Parent #1
Last
First
Middle
Maiden/Other names by which you are known
Street
Apt
City
State
Zip Code
Work
Cell
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Drivers License
Place of Birth (City State Country)
Social Security Number
Height
Weight
Hair Color
Eye Color
Adoptive Parent #2
Last
First
Middle
Maiden/Other names by which you are known
Street
Apt
City
State
Zip Code
Work
Cell
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Drivers License
Place of Birth (City State Country)
Social Security Number
Height
Weight
Hair Color
Eye Color
Household Information
Other adults who live in your home:

if none, please skip this information
Adult #1

First NameLast Name
Adult #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult #1 SSN
Adult #2

First NameLast Name
Adult #2 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult #2 SSN
Please list additional adults here:
Adoptive Parent Biological Family
Adoptive Parent 1 Biological Mother

First NameLast Name
Adoptive Parent 1 Biological Father

First NameLast Name
Please list siblings: include names, ages and relation (full, half and step)
Adoptive Parent 2 Biological Mother

First NameLast Name
Adoptive Parent 2 Biological Father

First NameLast Name
Please list siblings: include names, ages and relation (full, half and step)
Residential Information
Type of residence
Do you own or rent?
Total Square Footage
Number of Bedrooms
Number of Bathrooms
Current value
Monthly payment
How long at present address
How many times have you moved in the last 10 years?
Previous addresses of couple:
Military and Education History

Adoptive Parent 1
Branch
Dates of active duty

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Status
Highschool and Graduation Year
If your received a GED please complete the last grade completed and year you received your GED
Post Highschool education
include college or trade school attended, degree earned, and year attended
Military and Education History

Adoptive Parent 2
Branch
Dates of active duty

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Status
Highschool and Graduation Year
If your received a GED please complete the last grade completed and year you received your GED
Post Highschool education
include college or trade school attended, degree earned, and year attended
Marital/Relationship History List, in chronological order, all marriages, cohabitation or long term relationships,. Please also include any relationships resulting in children, even if the relationship is not considered significant. Include your current relationship. Use additional pages if necessary.

Adoptive Parent 1
Name of partner
Date of marriage or cohabitation:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce or separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Name of partner
Date of marriage or cohabitation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has there been any violence in any of your relationships, whether police were called or not?
If yes, please explain with who and circumstances:
Marital/Relationship History List, in chronological order, all marriages, cohabitation or long term relationships,. Please also include any relationships resulting in children, even if the relationship is not considered significant. Include your current relationship. Use additional pages if necessary.

Adoptive Parent 2
Name of partner
Date of marriage or cohabitation:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce or separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Name of partner
Date of marriage or cohabitation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employment History (Adoptive Parent 1)

Please include employment history for the past 10 years.
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Employer Name and Address
Dates of Employment
Reason for Leaving
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Employment History (Adoptive Parent 2)

Please include employment history for the past 10 years.
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Employer Name and Address
Dates of Employment
Reason for Leaving
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Has there been any violence in any of your relationships, whether police were called or not?
If yes, please explain with who and circumstances:
Medical History (Please list for both adoptive parents)

If you take any prescription medication, have a physical disability, chronic medical condition, or received psychiatric, psychological, or other behavioral health treatment, evaluation or counseling, please complete the followng information.
List any prescription medications you currently take with the dose and treatment provider's name.
Have either of you ever been hospitalized in a behavioral or psychiatric hospital?
Please list any hospitalizations you have had in the last 5 years INCLUDING behavioral health hospital stays.
Have either of you ever been treated for alcohol or substance abuse (this includes prescribed medication)

Other
If you stated yes above, please explain here:
Do either of you have any criminal history:
Please explain criminal history charges. Include arrest date, charge, probation and/or incarceration and release from charges.
Please provide the name of your probation or parole officer:

First NameLast Name
Please provide the telephone number of the probation or parole officer
Format: (000) 000-0000.
Has there ever been a protective order issued against you?
Please explain in detail the reason for a protective order:
Income and Budget
Adoptive Parent 1: Please list your monthly income (not including spouse or child support).
Please provide Mrs. Gordon with a pay stub or most recently filed W2.
Please provide any child or spousal support you receive.
Adoptive Parent 2: Please list your monthly income (not including spouse or child support).
Please provide Mrs. Gordon with a pay stub or most recently filed W2.
Please provide any child or spousal support you receive.
Approximately how much are your monthly bills?
List the primary children in adoption petition:
Child #1

First NameLast Name
Child #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #1 SSN
Child's School or Daycare and Grade
Child #2

First NameLast Name
Child #2 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #2 SSN
Child's School or Daycare and Grade
Child #3

First NameLast Name
Child #3 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #3 SSN
Child's School or Daycare and Grade
If you need additional room, please complete here:
Pediatrician's name:

First NameLast Name
Telephone number of the children's primary physician.
Format: (000) 000-0000.
Other children in the home:
Child #1

First NameLast Name
Child #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #1 SSN
Child's School or Daycare and Grade
Have any of the children been treated for a current or chronic health problem? If yes, which child, for what condition, and by who
Have any of the children received any behavioral/mental health counseling or treatment? If yes, which child, for what condition, and by who?
Are there any individuals who live with your part time, or full time who are not listed on this formIf yes, give their names, ages, and relationship to you:
Has anyone involved in this case ever been involved with Child Protective Services?

Other
If yes, please list dates, county, a brief description of the allegation and final outcome (ruled out, reason to believe, unable to determine or list unknown)
Please provide the biological parents information for the adopted child(ren)
Please list biological mother, last known residential city, biological father, last known residential city
Please provide the biological sibling information for the adopted child(ren)
If the child(ren) being adopted do not have any biological siblings, please leave this blank. If they do, please provide where they are placed and if you have contact with them.
Please answer the following questions.

If the question does not apply to your situation you may mark N/A.
1.Is this adoption open or closed? What contact if any are you willing to allow the biological family?
2. How has termination of biological parental rights affected the children? If rights have not yet been terminated, how do you think they will impact the child(ren)?
3.What do you feel are the children’s needs, strengths and weaknesses?
4. What activities do you enjoy with your children?
5. Describe yourself as a parent, focusing on your strengths.
6. List any concerns, not already stated, you have about parenting the child to be adopted.
7. Briefly describe your marriage or partnership with the other adoptive parent.
8. Adopted children often face struggles with identity, and abandonment issues, even in the most loving home. Are you willing to seek counseling for the adopted child(ren) if needed?
9. How will you explain adoption to your child?
10. Briefly describe your childhood, including who raised you and how. Include what resource or support your extended family is to you and the children. Please include for adoptive parent 1 and 2.
I agree these are my answers and my answers alone.
Should be Empty:

PERSONAL HISTORY QUESTIONNAIRE

Adoptive Parent #1

Adoptive Parent #2

Household Information

Other adults who live in your home:

Adoptive Parent Biological Family

Residential Information

Military and Education History

Military and Education History

Employment History (Adoptive Parent 1)

Employment History (Adoptive Parent 2)

Medical History (Please list for both adoptive parents)

Income and Budget

List the primary children in adoption petition:

Other children in the home:

Please answer the following questions.