THE ADOPTION CONSULTANCY

CONFIDENTIAL QUESTIONNAIRE



We take your privacy seriously. The Adoption Consultancy does not and 

will not sell any information to third parties. The Adoption Consultancy 

will not share any information that you provide to us without your express

consent as addressed in the “Agreement for Consulting Services.”





1. Family Information:



Family Name:____________________________________________________________



Street Address:_________________________________________________________



City, State, Zip:_______________________________________________________



County:_________________________________________________________________



Home Phone:_____________________ Home Fax:______________________________



Restrictions on where, when and through what means we may contact you:



________________________________________________________________________







2. Adopting Parent #1's Information:



Date of Marriage:_______________________________________________________



Name (Last, First):_____________________________________________________



Work Phone:_____________ Cell Phone:_____________ Work Fax:_____________



Email Address:_______________________ Citizenship:______________________



Race:___________________ DOB:__________________ Birthplace:_____________



Occupation:_________________________ Annual Income:_____________________



Prior Marriage(s)?__________ Reason for ending:_________________________



Number of Children from Previous Marriage(s):___________________________



Religion:________________________________ Active?_______________________



Health Status:__________________________________________________________



Is Infertility a Factor?________________________________________________





3. Adopting Parent #2's Information:



Name (Last, First):_____________________________________________________



Work Phone:______________ Cell Phone:____________ Work Fax:_____________



Email Address:______________________ Citizenship:_______________________





Race:____________________ DOB:__________________ Birthplace:____________



Occupation:__________________________ Annual Income:____________________



Prior Marriage(s)?:_________ Reason for ending:_________________________



Number of Children from Previous Marriage(s):___________________________



Religion:_____________________________ Active?:_________________________



Health Status:__________________________________________________________



Is Infertility a Factor?:_______________________________________________







4. Children in Your Family:_____________________________________________



Name:_______________ DOB:______________ From Prior Marriage?:___________



Living at Home?:_______________________ Adopted?:_______________________



Name:________________DOB:______________ From Prior Marriage?:___________



Living at Home?:_______________________ Adopted?:_______________________



Name:________________DOB:______________ From Prior Marriage?:___________



Living at Home?:_______________________ Adopted?:_______________________





5. Travel: (If necessary, could you and/or your spouse travel? If so, 

for how long could you be away?)



________________________________________________________________________



________________________________________________________________________





6. Adoption Budget: (Most adoptions will range from $30,000 to $45,000. 

It is not necessary to have all funds available when you begin your 

adoption process.)

________________________________________________________________________







7. Description of Child You Would Consider:



Age:_____  

(or circle) Newborn     Less than 1 year    1-2 years     2-5 years





Gender: Male     Female      No preference





Would you consider twins or siblings?:__________ 



If siblings, how many?:___________





Race:



Any Child:			Yes		No		Would consider

African American: 		Yes 		No 		Would consider

African American/Caucasian:	Yes		No 		Would consider

American Indian: 		Yes		No 		Would consider

American Indian/Caucasian: 	Yes		No 		Would consider

Asian: 				Yes		No 		Would consider

Asian/African American: 	Yes		No 		Would consider

Asian/Caucasian:		Yes		No 		Would consider

Caucasian: 			Yes		No 		Would consider

Hispanic or 

South/Central American: 	Yes		No 		Would consider

Hispanic/African American: 	Yes		No 		Would consider

Hispanic/Caucasian: 		Yes		No 		Would consider

Multi-racial: 			Yes		No 		Would consider

          



If you are considering international adoption, please indicate the 

countries in which you have an interest:



_______________________________________________________________________ 





_______________________________________________________________________







8. Additional Information: 

What is the most important factor of this adoption to you 

(i.e., time frame, child’s age, travel concerns, cost)? 



_______________________________________________________________________





_______________________________________________________________________





Is there anything else we should know about you or the child you would 

like to adopt that will assist us in finding the best sources for you? 



________________________________________________________________________





________________________________________________________________________







9. How did you hear about us? 



_______________________________________________________________________



_______________________________________________________________________