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REQUIRED
QUESTIONNAIRE FOR ADOPTIVE COUPLES
Husband's
Legal Name? First, MI, Last
Wife's
Legal
Name?
First, MI, Last
Address
City,
State, Zip
Numbers to Reach You? (Required).
Home Husband - Work Wife - Work
A
person who can ALWAYS contact you. (Required.)
Their
Phone Numbers? (Required.)
Home Work
HUSBAND'S
INFORMATION
Details
Hair:
Eyes:
Complexion:
Age:
Date
of Birth: Birthplace:
Prior
Marriages? Dates Dissolved:
National
Ancestry: Religion:
Occupation:
Income:
Education:
Do
you smoke? General Health:
Husband's
Specific Health Problems:
WIFE'S
INFORMATION
Details
Hair:
Eyes:
Complexion:
Age:
Date
of Birth: Birthplace:
Prior
Marriages? Dates Dissolved:
National
Ancestry: Religion:
Occupation:
Income:
Education:
Do
you smoke? General Health:
Wife's
Specific Health Problems:
MARRIAGE
INFORMATION
Date Place (City State) Where Marriage
Held:
Do
you own your Own/Rent?
Husband
& Wife's Hobbies
Husband
& Wife specific nature of infertility problem, if know?
Do
you have other Children? Names and Ages?
Do
they have any abnormalities?
OTHER
INFORMATION
Will
you accept a birth mother with drug usage?
Comments:
What
nationality child will you accept?
Any
other questions or comments?
Sender's
E-mail Address (Required):
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Couples must fill out the following questionnaire.