Confidential Questionnaire

adopted in

Confidential Questionnaire

Please submit your information via the secured form below. We take your privacy seriously; the secured form is protected from third party interception by the maximum 128-bit encryption and we will not sell or share any information to third parties without your express consent.

For your convenience, you may also print out and mail in the completed questionnaire. It is provided in a PDF and TEXT based formatting:

You may then mail the completed form to:

The Adoption Consultancy
503 E. Jackson St., Suite 324
Tampa, FL 33602

Family Information

Family Name:

Street Address:

City, State, Zip:

County:

Best Phone Number:

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

Adopting Parent #1’s Information

Date of Marriage:

Name (Last, First):

Work Phone:

Cell Phone:

Email:

Citizenship:

Race:

DOB:

Birthplace:

Occupation:

Annual Income:

Prior Marriage(s)?:

Yes No

Reason for ending:

Number of Children from Previous Marriage(s):

Religion:

Active?

Yes No

Health Status:

Is Infertility a Factor?

Yes No

Adopting Parent #2’s Information

Name (Last, First):

Work Phone:

Cell Phone:

Email:

Citizenship:

Race:

DOB:

Birthplace:

Occupation:

Annual Income:

Prior Marriage(s)?

Yes No

Reason for ending:

Number of Children from Previous Marriage(s):

Religion:

Active?

Yes No

Health Status:

Is Infertility a Factor?

Yes No

Children in Your Family

Children's Names/DOB:

Any Children from Prior Marriage?

Yes No

If Yes, which ones?

Any Children Living at Home?

Yes No

If Yes, which ones?

Any Children Adopted? If Yes, which ones?

Travel

If necessary, could you and/or your spouse travel? If so, for how long could you be away?

Adoption Budget

Most adoptions range from low $50,000s to low $60,000s. It is not necessary to have all funds available when you begin your adoption process.

Description of Child You Would Consider

Age:

Newborn <1yr 1-2yr 2-5yr

Gender:

Male Female No preference

Would you consider twins or siblings?

Yes No

If siblings, how many?

Race:

Any Child:

Yes No Consider

African American:

Yes No Consider

African American/Caucasian:

Yes No Consider

American Indian:

Yes No Consider

American Indian/Caucasian:

Yes No Consider

Asian:

Yes No Consider

Asian/African American:

Yes No Consider

Asian/Caucasian:

Yes No Consider

Caucasian:

Yes No Consider

Hispanic or South/Central American:

Yes No Consider

Hispanic/African American:

Yes No Consider

Hispanic/Caucasian:

Yes No Consider

Multi-racial:

Yes No Consider

If you are considering international adoption, in which countries do you have an interest:

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?

How did you hear about us?

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