Close Relative Adoption Intake Questionnaire

Close-Relative Adoption Intake Questionnaire
This form collects the facts needed to prepare the close-relative adoption petition and the Virginia VS-21 Report of Adoption.
Close-relative petitioner 1 and contact
Petitioner 1 first name
Petitioner 1 middle name
Petitioner 1 last name
Petitioner 1 suffix
Petitioner 1 date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Petitioner 1 birth or maiden last name
Petitioner 1 pronouns
Petitioner 1 custom pronouns
Petitioner 1 relationship to child
Petitioner 1 relationship description
Petitioner 1 street address
Petitioner 1 city
Petitioner 1 state
Petitioner 1 ZIP
Petitioner 1 phone
Please enter a valid phone number.Format: (000) 000-0000.
Petitioner 1 email
example@example.com
Date petitioner 1 and child began living in the same household

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Petitioner 1 street address when child was born
Petitioner 1 city when child was born
Petitioner 1 state when child was born
Petitioner 1 ZIP when child was born
Is there a second close-relative petitioner?
Second close-relative petitioner
Petitioner 2 first name
Petitioner 2 middle name
Petitioner 2 last name
Petitioner 2 suffix
Petitioner 2 date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Petitioner 2 birth or maiden last name
Petitioner 2 pronouns
Petitioner 2 custom pronouns
Petitioner 2 relationship to child
Petitioner 2 relationship description
Petitioner 2 street address
Petitioner 2 city
Petitioner 2 state
Petitioner 2 ZIP
Date petitioner 2 and child began living in the same household

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Petitioner 2 street address when child was born
Petitioner 2 city when child was born
Petitioner 2 state when child was born
Petitioner 2 ZIP when child was born
Child to be adopted
Adoptee current first name
Adoptee current middle name
Adoptee current last name
Adoptee current suffix
Adoptee date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State of birth
Country of birth
Birth certificate number
Adoptee pronouns
Adoptee custom pronouns
Has the adoptee ever used a different legal name?
Adoptee prior legal name at birth or earliest prior name
Will the adoptee's legal name change after adoption?
Adoptee new first name
Adoptee new middle name
Adoptee new last name
Adoptee new suffix
Date the adoptee began residing with petitioner 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth parent 1
Birth parent 1 first name
Birth parent 1 middle name
Birth parent 1 last name
Birth parent 1 suffix
Birth parent 1 relationship
Birth parent 1 date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth parent 1 state of birth
Birth parent 1 country of birth
Birth parent 1 pronouns
Birth parent 1 custom pronouns
Has birth parent 1 used former last names?
Birth parent 1 former last names
Is birth parent 1 deceased?
Birth parent 1 consent or legal basis
Birth parent 1 street address
Birth parent 1 city
Birth parent 1 state
Birth parent 1 ZIP
Birth parent 2
Birth parent 2 first name
Birth parent 2 middle name
Birth parent 2 last name
Birth parent 2 suffix
Birth parent 2 relationship
Birth parent 2 date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth parent 2 state of birth
Birth parent 2 country of birth
Birth parent 2 pronouns
Birth parent 2 custom pronouns
Has birth parent 2 used former last names?
Birth parent 2 former last names
Is birth parent 2 deceased?
Birth parent 2 consent or legal basis
Were the two birth parents married to each other?
Birth parent 2 street address
Birth parent 2 city
Birth parent 2 state
Birth parent 2 ZIP
Should be Empty:

Close-Relative Adoption Intake Questionnaire

Close-relative petitioner 1 and contact

Second close-relative petitioner

Child to be adopted

Birth parent 1

Birth parent 2