Dear Adoptive Family

Dear Prospective Adoptive Parent(s),
Thank you for choosing Heart of Adoptions, Inc. to complete your adoption home
study. We are pleased to share in your expectations for a successful adoption. Heart of
Adoptions, Inc. is a full service, licensed adoption agency located in the state of Florida.
It is our goal to provide professional and quality adoption services to families hoping to
build their family through adoption.
Some of the services we provide adoptive families include:
Home Studies
Post Placement Supervision
Adoption Placement Services
Interstate Compact Services
Counseling
Adoption Education
Experienced Staff
We understand that adopting a child can be overwhelming and emotionally
challenging at times. Our knowledgeable staff is available to walk you step by step
through the adoption process as you complete the necessary forms for your home study.
One of our highly trained professionals will complete your home study, and after your
child comes home, we will provide any legally required post placement supervision visits
to insure that you and your new child are doing well. Your home study professional will
provide you with guidance and support, as well as referrals for any additional services
that your family may request.
Please follow the enclosed detailed instructions to begin the home study process.
We look forward to meeting your family soon and wish you much success on your
adoption journey!
Respectfully,
Mary A. Wheatley, M.S.
Executive Director
WHAT IS A HOME STUDY?
A home study is a review of you, your spouse, and anyone else living in your home. It
highlights items such as relationships, interactions with children, your neighborhood, and
your childhood. Initially the home study process frightens some families until they actually
complete one. We try to make the process both easy and relaxing. The home study helps the
courts and our agency determine if a stable environment exists for a family to receive an
adoptive placement.
Collecting all the documents for the home study can be time consuming. Items such as a
marriage license, driver’s license, and birth certificate are required to legally confirm your
identity.
WHO SHOULD COMPLETE OUR HOME STUDY?
Adoptive families enjoy the following advantages of our home study:
 Our home study can be used virtually anywhere in the United States. It is important to
note that in many states, only home studies from licensed adoption agencies are accepted.
In those situations, if you have selected someone other than a licensed agency to
complete your home study, you may be required to have a qualified agency perform
another home study for you. That means increasing your costs and possibly the wait to
receive a child.
 We are able to complete home studies more quickly than most agencies.
 Our home study is less expensive than nearly all the other programs in Florida. We have
a reasonable base fee for the home study and low fees for post-placement visits and home
study updates, while other programs charge significantly higher fees for these services.
WHAT ARE POST-PLACEMENT SUPERVISION VISITS?
Post-placement supervision visits are follow-ups to the home study after a child is placed in
your home. They consist of visits or contacts from a social worker to assess the status of the
child and how the adoptive parents are adjusting. Once a child is placed in your home,
please notify us immediately. Our agency will perform the required number of postplacement visits to ensure completion in time for finalization. While each state varies on
post-placement visit requirements, on average 3 visits or contacts are required within the first
3 months after placement. Quarterly visits thereafter may also be required.
WHAT IS A HOME STUDY UPDATE/ADDENDUM?
A home study update/addendum is a required addition to the home study in the event of an
address change, any major life changes or after a certain amount of time has passed (1 year in
Florida). It is important that you notify us immediately following any events or life changes.
WHAT IS THE DIFFERENCE IN AN INTERNATIONAL HOME STUDY?
An international home study is somewhat different than a domestic home study. With an
international home study, the requirements of your home state need to be met, in addition to
the requirements of the Immigration and Naturalization Service and the foreign country. An
international home study is a highly specialized style of home study that needs to be
completed by a licensed adoption agency. If you are in need of an international home study
rather than a domestic home study, email us info@heartofadoptions.com for information on
international home study services.
HOME STUDY INSTRUCTIONS
STEP #1: Complete the following items and mail them in to our Tampa office, along with your payment
for services:
1.
DOMESTIC HOME STUDY AGREEMENT (form enclosed)
2.
LOCAL CRIMINAL RECORD CHECK* – you will need to go to your local sheriff’s office and
request a local criminal record check (instructions enclosed) on all household members age 12 or older.
3.
STATE/FEDERAL FINGERPRINT CHECK* – this report verifies your identity and state and
national criminal record. You will need to go to an electronic fingerprint provider nearest you
(instructions enclosed). All household members age 12 or older must be fingerprinted. There is a fee for
each person being fingerprinted.
4.
CENTRAL ABUSE HOTLINE RECORD SEARCH* & RELEASE OF INFORMATION (forms
enclosed) – this form is submitted by our agency to the Florida Department of Children and Families
(DCF) protective services system to check for any involvement with the neglect, abuse or exploitation of
a child. You must complete both pages of this form and mail the signed original to our agency. All
household members, including anyone listed on page 1, must be listed on the top of page 2. You must
also sign and mail the original of the DCF Release of Information that must accompany the abuse hotline
record search. This should be completed and returned to us as soon as possible, since processing and
clearance can take up to thirty days to receive back.
5.
AFFIDAVIT OF GOOD MORAL CHARACTER* – all adult household members must sign this
(form enclosed) in front of a Notary Public and have it notarized. The signed and notarized original form
should be mailed back to the agency. Please make additional copies as needed for other adults in the
home.
*If you have a child abuse/neglect history or have ever been arrested or have a criminal history of any
king, you must provide dispositions and explanations of the events regardless of whether the arrest or
charge was dropped or expunged from your record.
6.
ADOPTION DISCLOSURE (form enclosed)
7.
AUTHORIZATION FOR RELEASE OF INFORMATION (form enclosed)
8.
CONTACT & IDENTIFYING INFORMATION (form enclosed)
9.
BIOGRAPHICAL INFORMATION (form enclosed) – each prospective adoptive parent should
complete this narrative form separately. Please be sure to answer all questions thoroughly.
10.
FIREARM SAFETY ACKNOWLEDGEMENT (form enclosed)
STEP #2: The collection of these documents can seem somewhat overwhelming at first, but in reality
they are easy to obtain. You may e-mail items that only require a copy, but please mail in any documents
that have an original signature.
1.
FIVE (5) REFERENCE LETTERS – provide five letters of reference addressing the following
information about the prospective adoptive parent(s): the references name, address, email address, and
phone number; how long have they known you and in what capacity; how they feel you interact with
children; and why they think you would be good parents. Two of your references may be relatives, but
the other three must be non-relatives. Please have the reference mail their signed letter into our Tampa
office.
2.
BIRTH CERTIFICATE(S) – submit a copy of each household member’s birth certificate. If a
prospective adoptive parent or household member was not born in the United States of America, also
provide proof of citizenship or residency.
3.
DRIVER’S LICENSE(S) – provide a photo copy of all adult household member’s driver’s
license or identification card.
4.
MARRIAGE LICENSE – if applicable, provide a copy of your marriage record.
5.
DIVORCE DECREE(S) – if applicable, provide a copy of your divorce decree(s).
6.
ADOPTION DECREES(S) – if applicable, provide copies of all Final Judgments of adoption for
all adopted children in the home.
7.
MILITARY DISCHARGE(S) – if applicable, provide a copy of your military discharge orders.
8.
INCOME TAX RETURN – provide a copy of the first two pages only of your latest income tax
return.
9.
INSURANCE VERIFICATION – provide a photo copy of the health insurance card (front and
back) that will begin covering your child at placement.
10. EMPLOYMENT VERIFICATION (form enclosed) – submit to your employer for completion. If
you are self-employed, please have a business partner or your tax accountant complete this form or write
a letter.
11. HEALTH STATEMENTS FROM A PHYSICIAN (forms enclosed) – you must have had a
physical check-up within the last year. Have your primary care physician or a clinic complete the
enclosed form for you and any other children or adult household members. Please make copies of the
enclosed forms for additional household members as needed.
12.
FAMILY MONTHLY BUDGET (form enclosed)
DOMESTIC HOME STUDY AGREEMENT
Heart of Adoptions, Inc. agrees to conduct a home study investigation of the prospective
adoptive parent(s). If HEART OF ADOPTIONS, INC. deems the prospective adoptive
parent(s) unsuitable for adoption, HEART OF ADOPTIONS, INC. will inform the
parent(s) and provide no additional services under this agreement. The determination
regarding approval or disapproval of the prospective adoptive family is within the sole
discretion of HEART OF ADOPTIONS, INC. The prospective adoptive parent(s)
acknowledges that HEART OF ADOPTIONS, INC. makes no guarantees that the
adoptive parent’s home study will be approved or that an approved home study will result
in a child being placed with the prospective adoptive parent(s). The prospective adoptive
parent(s) agrees to hold harmless HEART OF ADOPTIONS, INC. in the event that they
are not approved for the adoption of a child.
The Adoptive Home Study Evaluation fee of $900 is due and payable upon request of
services. Travel will be billed at $20 per hour for drive time plus mileage at the standard
federal rate for visits made by the caseworker outside the city limits of the nearest office
of HEART OF ADOPTIONS, INC. (Tampa, Naples or Orlando). Travel reimbursement
for the caseworker, if applicable, will be reimbursed at the time of the home visit with a
separate check payable directly to the caseworker. All fees are NON-REFUNDABLE.
The prospective adoptive family is responsible for a $25 fee (plus costs, if any) for
criminal or child abuse clearance requests from jurisdictions other than the jurisdiction of
current residence. These additional clearance requests may be required in order to comply
with our state licensing regulations and the Adam Walsh Act. This fee is NONREFUNDABLE.
The prospective adoptive family is also responsible for the fees associated with obtaining
state/federal and local background checks and reports for all occupants in the household
age 12 and older. This fee is payable directly to the police department, sheriff’s office,
and/or the electronic fingerprint provider utilized. This fee is NON-REFUNDABLE.
During the home study process, HEART OF ADOPTIONS, INC. will advise the
prospective adoptive parent(s) as to what adoption education, if any, will be required. We
encourage all prospective adoptive parents to seek out as much adoption education as
possible. Please explore the variety of adoption books available at
www.tapestrybooks.com. We also recommend the following adoption education
providers: Adoption Learning Partners (www.adoptionlearningpartners.org) and My
Adoption Advisor (www.myadoptionadvisor.com). All fees associated with required
classes are the responsibility of the prospective adoptive parent(s).
HEART OF ADOPTIONS, INC. may require a psychological assessment or any other
documentation deemed pertinent before approving or disapproving a prospective adoptive
parent. All required psychological assessments and any other documentation are to be
provided at the expense of the prospective adoptive parent(s).
Although most home studies can be completed in 6-8 weeks, prospective adoptive
families may request an expedited home study for emergency situations. The expediting
fee of $250 is due and payable upon request of services and is NON-REFUNDABLE.
The prospective adoptive parent(s) understands that there are certain legal procedures
involved in the home study that cannot be avoided and could delay the final approval of
the home study. Expedited home study requests are limited to situations where the
prospective adoptive child’s birth is imminent or placement of the child is of an urgent
nature.
The prospective adoptive family will receive one original copy of their home study report.
They will also receive copies of HEART OF ADOPTIONS, INC.’S agency license as
issued by the Florida Department of Children and Families and all other supportive
documentation required by the State where they are adopting, provided this information
can be released by HEART OF ADOPTIONS, INC.
In Florida, home study reports are valid for one year/twelve months from the date of
completion. If the adoptive family does not receive placement of an adoptive child within
one year/twelve months, a home study update will be needed. Any subsequent home
study updates (usually completed if the initial report nears one year/twelve months old)
conducted for the prospective adoptive family will be provided for the base fee of $500
(plus costs) and is due and payable upon request of services. This fee is NONREFUNDABLE.
Revisions or addendums to a home study (i.e. family relocates, someone new moves into
home, etc.) after the final report has been written and approved is assessed at $100 per
hour. This fee is due and payable at the time that the changes are made. This fee is
NON-REFUNDABLE.
Once you have an approved home study, you are able to serve as a temporary caretaker to
children Heart of Adoptions, Inc. has matched with their forever family but the family is
unable to take immediate placement. Please note these children are not available to be
adopted by you, but instead need short term care. Please contact your social worker if
you are interested in serving as a temporary caretaker. The placements can be days to
weeks in length, but are typically very short-term.
The Post-Placement fee of $200 per report is due and payable upon request of services.
The agency will conduct a minimum of three visits after the placement of a child and, if
needed, quarterly visits thereafter prior to the Petition for Adoption being filed. Travel for
these visits will be billed at $20 per hour for drive time plus mileage at the standard
federal rate for visits made by the caseworker outside the city limits of the nearest office
of HEART OF ADOPTIONS, INC. (Tampa, Naples or Orlando). Travel reimbursement
for the caseworker, if applicable, will be reimbursed at the time of the visit with a
separate check payable directly to the caseworker. This fee is NON-REFUNDABLE.
I/We understand that in the course of the adoption process, certain documents considered
to be confidential may be made available to persons for specific purposes related to the
adoption process. I/We authorize HEART OF ADOPTIONS, INC. to release such
information as deemed necessary.
The withholding of information or the providing of incorrect information which is
material to HEART OF ADOPTIONS, INC.’S legal responsibility to investigate a
prospective adoptive parent’s suitability as an adoptive parent in connection with either
existing or prospective adoption proceedings, or in anticipation of the placement of a
child for adoption with applicant by HEART OF ADOPTIONS, INC. or another adoption
professional, is grounds for the immediate termination of this agreement by HEART OF
ADOPTIONS, INC. and a forfeiture of all payments made by the applicant to HEART OF
ADOPTIONS, INC. up to the date of termination. Examples of material omission or
misrepresentations of applicants which may prompt HEART OF ADOPTIONS, INC. to
terminate the agreement are as follows: the withholding of information or the providing
of incorrect information relating to an arrest or the alleged commission of a misdemeanor
or felony, or any criminal record arising out of an arrest; the withholding of information
or the providing of incorrect information concerning the applicant’s biographical, socialeconomic or medical histories Information is deemed to be material under this agreement
if it has a bearing on HEART OF ADOPTIONS, INC.’S assessment that the adoptive
parent(s) is qualified to adopt the child.
The prospective adoptive parent(s) and HEART OF ADOPTIONS, INC. understand that
because each party has entered into this agreement voluntarily, either party may terminate
this agreement and the adoption process by giving written notice to the other party.
A true and accurate copy hereof is as effective as an original for all purposes.
_________________________________________
Prospective Adoptive Parent (1)
_____________________
Date
_________________________________________
Prospective Adoptive Parent (2)
_____________________
Date
Local Criminal Record Check
All household members age 12 or older must submit local background checks.
The adoption home study process in the state of Florida requires a current local criminal
background check on all household members age 12 or older. It will be necessary for you
to go to your local Sheriff’s Department and request a “local” background check. It may
be wise to call your local Sheriff’s Office first to see if there is a charge for this service or
if there is any documentation you should bring with you.
Should there be any reported criminal history, it will be necessary for you to obtain any
and all reports and arrest dispositions, as well as provide a written explanation as to the
circumstance involving law enforcement.
State/Federal Fingerprint Clearance
NOTE: All household members age 12 or older must be fingerprinted.
Fingerprints are done by appointment only at the location that you chose. Typically the
appointments must be scheduled at least 24 hours in advance and may be prepaid by
credit card, debit card, or e-check.
HOW TO OBTAIN AN APPOINTMENT:
STEP 1: Register online at www.identogo.com or by calling 1-800-528-1358.
STEP 2: When the appointment is scheduled, choose “VECHS” from the drop
down list. If phone registration, inform the operator the request is for
“VECHS.”
STEP 3: Chose Volunteer and enter the Qualified Entity Number: 29030003.
Should there be any reported criminal history, it will be necessary for you to obtain any
and all reports and arrest dispositions, as well as provide a written explanation as to the
circumstance involving law enforcement.
ADOPTION DISCLOSURE AND
ACKNOWLEDGMENT OF RECEIPT OF ADOPTION DISCLOSURE
THE STATE OF FLORIDA REQUIRES, PURSUANT TO CHAPTER 63 OF THE
FLORIDA STATUTES, THAT THIS FORM BE PROVIDED TO ALL PERSONS
CONSIDERING ADOPTING A MINOR OR SEEKING TO PLACE A MINOR FOR
ADOPTION, TO ADVISE THEM OF THE FOLLOWING FACTS REGARDING ADOPTION
UNDER FLORIDA LAW:
1.
The name, address and telephone number of the adoption entity providing this
disclosure is:
HEART OF ADOPTIONS, INC.
418 WEST PLATT STREET, SUITE A
TAMPA, FL 33606
813-258-6505
2.
The adoption entity does not provide legal representation or advice to parents or
anyone signing a consent for adoption or affidavit of non-paternity and parents have the right to
consult with an attorney of their own choosing to advise them. THIS MEANS THAT THE
ADOPTION ENTITY'S ATTORNEYS, JEANNE T. TATE, DANELLE D. BARKSDALE,
MARTHA A. CURTIS, STEVEN HURWITZ, NICOLE WARD MOORE, AND ROBERT L.
WEBSTER III, DO NOT AND CANNOT REPRESENT THE BIRTH PARENTS.
THE
ADOPTION ENTITY'S FEES AND ATTORNEY FEES ARE PAID FOR BY THE
PROSPECTIVE ADOPTIVE PARENTS. ADDITIONALLY, JEANNE T. TATE IS THE SOLE
OWNER AND PRESIDENT OF THE ADOPTION ENTITY.
3.
With the exception of an adoption by a stepparent or relative, a minor child cannot be
placed into a prospective adoptive home unless the prospective adoptive parents have received a
favorable preliminary home study, including criminal and child abuse clearances.
4.
A valid consent for adoption may not be signed by the birth mother until 48 hours after
the birth of the child, or the day the birth mother is notified, in writing, that she is fit for discharge
from the licensed hospital or birth center. Any man may sign a valid consent for adoption at any
time after the birth of the child. An affidavit of non-paternity may be executed before the birth of
the minor.
5.
A consent for adoption signed before the child attains the age of 6 months is binding
and irrevocable from the moment it is signed unless it can be proven in court that the consent was
obtained by fraud or duress. A consent for adoption signed after the child attains the age of 6
months is valid from the moment it is signed; however, it may be revoked up to 3 business days
after it was signed.
6.
A consent for adoption is not valid if the signature of the person who signed the
consent was obtained by fraud or duress.
7.
An unmarried biological father must act immediately in order to protect his parental
rights. §63.062, Florida Statutes, prescribes that any father seeking to establish his right to consent
to the adoption of his child must file a claim of paternity with the Florida Putative Father Registry
maintained by the Office of Vital Statistics of the Department of Health by the date a petition to
terminate parental rights is filed with the court, or within 30 days after receiving service of a Notice
of Intended Adoption Plan (if applicable). If he receives a Notice of Intended Adoption Plan, he
must file a claim of paternity with the Florida Putative Father Registry, file a parenting plan with
the court, and provide financial support to the mother or child within 30 days following service.
An unmarried biological father's failure to timely respond to a Notice of Intended Adoption Plan
constitutes an irrevocable legal waiver of any and all rights that the father may have to the child. A
claim of paternity registration form for the Florida Putative Father Registry may be obtained from
any local office of the Department of Health, Office of Vital Statistics, the Department of Children
and Families, the Internet websites for these agencies, and the offices of the clerks of the Florida
circuit courts. The claim of paternity form must be submitted to the Office of Vital Statistics,
Attention: Adoption Unit, P.O. Box 210, Jacksonville, FL 32231.
8.
There are alternatives to adoption, including foster care, relative care, and parenting
the child. There may be services and sources of financial assistance in the community available to
parents if they choose to parent the child.
9.
A parent has the right to have a witness of his or her choice, who is unconnected with
the adoption entity or the adoptive parents, to be present and witness the signing of the consent or
affidavit of non-paternity.
10.
A parent 14 years of age or younger must have a parent, legal guardian, or court-
appointed guardian ad litem to assist and advise the parent as to the adoption plan and to witness
consent.
11.
A parent has a right to receive supportive counseling from a counselor, social worker,
physician, clergy, or attorney.
12.
The payment of living or medical expenses by the prospective adoptive parents before
the birth of the child in no way obligates the parent to sign the consent for adoption.
Acknowledgment of Disclosure and acknowledgment that I received a copy of this Disclosure for
my records:
Signature: _____________________
Signature: ________________________
Print Name: ____________________
Print Name: _______________________
Date: _________________________
Date: ____________________________
Time: ________________________
Time: ____________________________
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize the release of any information requested by Heart of Adoptions, Inc. to be
utilized in determining my suitability to become an adoptive parent.
I hereby grant permission for Heart of Adoptions, Inc. to obtain information from local, state or
federal law enforcement agencies to help determine my suitability to serve as an adoptive parent.
I understand, however, that a history of arrest reported by any of these agencies will not
necessarily prohibit my application in the adoption program.
Pursuant to Florida Statute §39.202(2)(a)5, I hereby authorize Heart of Adoptions, Inc. to make
inquiry of the central abuse registry and tracking system in regard to the existence of any report
of abuse, neglect, or exploitation and the results of any investigation pursuant hereto.
Furthermore, I hereby grant permission for Heart of Adoptions, Inc. to obtain medical or
psychiatric information from medical providers to help determine my suitability to serve as an
adoptive parent.
Lastly, I hereby authorize Heart of Adoptions, Inc. to disclose information obtained pursuant to
this release to the following persons or organizations: Attorneys for adoptive parents; Attorneys
for adoption agency; Agency for adoptive parents; Court in connection with adoption, as
necessary; Interstate Compact on the Placement of Children, as necessary; and spouse/partner of
adoptive parent.
This authorization contemplates the sharing of information that might otherwise be protected and
is intended to constitute a release of confidential and privileged information and communication.
I understand that this authorization will remain in effect indefinitely unless I withdraw my
consent in writing.
_________________________________________
Prospective Adoptive Parent (1) Signature
_______________
Date
_________________________________________
Prospective Adoptive Parent (2) Signature
_______________
Date
_________________________________________
Adult Household Member
_______________
Date
_________________________________________
Adult Household Member
_______________
Date
Contact and Identifying Information
PARENT 1 NAME: ________________________________________________________________________________
Full Legal Name (First, Middle, Last)
Maiden or A/K/A
___________________________________
Social Security Number
_______________________
Date of Birth
PARENT 2 NAME: ________________________________________________________________________________
Full Legal Name (First, Middle, Last)
Maiden or A/K/A
___________________________________
Social Security Number
_______________________
Date of Birth
HOME ADDRESS: ________________________________________________________________________________
(Street, City, County, State, Zip)
CONTACT INFORMATION:
___________________________
Home Phone
___________________________
Parent 1 Cell Phone
___________________________________
Parent 1 E-Mail
__________________________
Parent 2 Cell Phone
___________________________________
Parent 2 E-Mail
IDENTIFYING & PHYSICAL INFORMATION:
PARENT 1
PARENT 2
HEIGHT
____________________
____________________
WEIGHT
____________________
____________________
HAIR COLOR
____________________
____________________
EYE COLOR
____________________
____________________
COMPLEXION
____________________
____________________
BODY STRUCTURE
____________________
____________________
RACE
____________________
____________________
ETHNICITY
____________________
____________________
PROSPECTIVE ADOPTIVE PARENT
BIOGRAPHICAL INFORMATION
Please answer the following questions as completely as possible in narrative form.
Each adopting parent should complete their own narrative separately.
Family Background Information:
Parent’s names, ages, location, health, and occupations. If deceased, state cause of death and when.
Describe your relationship with your parents growing up and how it is today. Sibling names, ages,
location, health, occupations, marital status, and children. Describe your relationship with your
sibling(s) growing up and how it is today.
Childhood:
Describe where you grew up and what your childhood was like including your parents’ methods of
discipline and how they interacted with you as a child. Explain if and how you will differ from them in
how you were raised. How did your parents treat each other? Did your parents have a problem (i.e.
alcoholism, violence, etc.) that may have affected your childhood development? If so, please describe the
problem and how you coped.
Education:
List schools attended (high school and college), including location and years. What activities were you
involved in, including special interests or major accomplishments. Describe degrees obtained. Did you
work during this time? If so, describe.
Employment:
What is your job title? Describe your job duties. How long have you been in your current position? Do
you have any plans to change employment in the near future? What is the salary structure? Are bonuses
part of the structure? Clarify if salary is different than what tax return shows.
Relationships:
How/when did you meet your partner/significant other? If married, how long did you date before
marriage? What attracted you to your partner? How do you and your partner relate to one another?
What is your communication style and how are disagreements resolved? What is the best part about
being together? If previously married/in significant long-term relationship, state date of
marriage/relationship and dissolution. What is your relationship with your former partner?
Explain how you generally get along with people. Do you have a small circle of close friends or many
relationships? Who do you spend most of your time with? Who do you turn to for support during
difficult times? Have you experienced any special, unusual or traumatic circumstances that impacted
your development or how you relate to others?
Children:
If you have children, do they live with you? Are they from a previous marriage or relationship? If so,
explain custody/visitation arrangements. Describe your relationship with your son(s)/daughter(s) and
their personality. Do they know about your adoption plans? Are they supportive of your plans?
Please describe your child rearing philosophy? (i.e. what you hope to teach your child, how you will
interact with your child, values you hope to pass along, etc). How do you plan to discipline your child?
Have you had any formal education to prepare yourself and improve your abilities to parent a child?
What is your childcare arrangement? Will you work or stay home with your child?
Guardianship:
What plans will you make for your child’s future should something happen to you? Please list the
name(s) of the individual(s) you plan to name as guardians and include their names, number of children,
jobs, where they reside and why you chose them? If you have children at this time, is this arrangement
already in a will?
Religious/ Spiritual:
Does religion play an important role in your life? If yes, describe. How will your religious beliefs be
incorporated into your parenting? Do you plan on raising your child with a specific faith/religion?
Home and Community:
Describe your current housing arrangement (i.e. house, condo, apartment, etc.) including size,
appearance, furnishings, # of smoke alarms, etc.? How long have you lived in this home? Describe your
neighborhood (i.e. diverse, close-knit, etc.) Do you have a swimming pool? Do you have the proper
safety fence? If your home is near a body of water, what steps have you taken to ensure water safety?
Leisure/Recreational:
Describe any special areas of interest or hobbies (i.e. art, books, crafts, shopping, exercising, outdoor
activities, fishing, hunting, traveling, etc.) How often do you do these activities?
Health:
State any past or present health issues/disabilities. Have you ever received any psychiatric or therapeutic
treatment? If yes, state when, along with outcome and current status. Explain any history of substance
abuse or current problems with drugs/alcohol.
Legal:
Are you involved in any active cases (traffic, civil, criminal, probation, etc.)? If yes, describe in detail
including dates, locations, and charges. Do you have any history of any legal issues? If yes, describe in
detail including dates, locations, charges, and dispositions. Please write an explanation for each incident
even if the charges were dropped.
Thoughts about adoption:
When did you first start thinking about adoption and why? If infertility is present, explain what medical
consultation you received and your reaction then and now. Are you still pursuing medical treatment to
conceive? Describe if and how you have resolved your feelings about infertility, or if you are still
working through this process.
How do you think you will feel towards the birth parents of your child? What adoption education have
you received up to this point?
Reason for Home Study:
How were you referred to our agency? Please state your reason for completing a home study at this time.
If you are currently matched with a birth mother or are matched with a born child, please describe how
you came to be matched and/or why you wish to adopt this specific child.
PROSPECTIVE ADOPTIVE PARENT
BIOGRAPHICAL INFORMATION
Please answer the following questions as completely as possible in narrative form.
Each adopting parent should complete their own narrative separately.
Family Background Information:
Parent’s names, ages, location, health, and occupations. If deceased, state cause of death and when.
Describe your relationship with your parents growing up and how it is today. Sibling names, ages,
location, health, occupations, marital status, and children. Describe your relationship with your
sibling(s) growing up and how it is today.
Childhood:
Describe where you grew up and what your childhood was like including your parents’ methods of
discipline and how they interacted with you as a child. Explain if and how you will differ from them in
how you were raised. How did your parents treat each other? Did your parents have a problem (i.e.
alcoholism, violence, etc.) that may have affected your childhood development? If so, please describe the
problem and how you coped.
Education:
List schools attended (high school and college), including location and years. What activities were you
involved in, including special interests or major accomplishments. Describe degrees obtained. Did you
work during this time? If so, describe.
Employment:
What is your job title? Describe your job duties. How long have you been in your current position? Do
you have any plans to change employment in the near future? What is the salary structure? Are bonuses
part of the structure? Clarify if salary is different than what tax return shows.
Relationships:
How/when did you meet your partner/significant other? If married, how long did you date before
marriage? What attracted you to your partner? How do you and your partner relate to one another?
What is your communication style and how are disagreements resolved? What is the best part about
being together? If previously married/in significant long-term relationship, state date of
marriage/relationship and dissolution. What is your relationship with your former partner?
Explain how you generally get along with people. Do you have a small circle of close friends or many
relationships? Who do you spend most of your time with? Who do you turn to for support during
difficult times? Have you experienced any special, unusual or traumatic circumstances that impacted
your development or how you relate to others?
Children:
If you have children, do they live with you? Are they from a previous marriage or relationship? If so,
explain custody/visitation arrangements. Describe your relationship with your son(s)/daughter(s) and
their personality. Do they know about your adoption plans? Are they supportive of your plans?
Please describe your child rearing philosophy? (i.e. what you hope to teach your child, how you will
interact with your child, values you hope to pass along, etc). How do you plan to discipline your child?
Have you had any formal education to prepare yourself and improve your abilities to parent a child?
What is your childcare arrangement? Will you work or stay home with your child?
Guardianship:
What plans will you make for your child’s future should something happen to you? Please list the
name(s) of the individual(s) you plan to name as guardians and include their names, number of children,
jobs, where they reside and why you chose them? If you have children at this time, is this arrangement
already in a will?
Religious/ Spiritual:
Does religion play an important role in your life? If yes, describe. How will your religious beliefs be
incorporated into your parenting? Do you plan on raising your child with a specific faith/religion?
Home and Community:
Describe your current housing arrangement (i.e. house, condo, apartment, etc.) including size,
appearance, furnishings, # of smoke alarms, etc.? How long have you lived in this home? Describe your
neighborhood (i.e. diverse, close-knit, etc.) Do you have a swimming pool? Do you have the proper
safety fence? If your home is near a body of water, what steps have you taken to ensure water safety?
Leisure/Recreational:
Describe any special areas of interest or hobbies (i.e. art, books, crafts, shopping, exercising, outdoor
activities, fishing, hunting, traveling, etc.) How often do you do these activities?
Health:
State any past or present health issues/disabilities. Have you ever received any psychiatric or therapeutic
treatment? If yes, state when, along with outcome and current status. Explain any history of substance
abuse or current problems with drugs/alcohol.
Legal:
Are you involved in any active cases (traffic, civil, criminal, probation, etc.)? If yes, describe in detail
including dates, locations, and charges. Do you have any history of any legal issues? If yes, describe in
detail including dates, locations, charges, and dispositions. Please write an explanation for each incident
even if the charges were dropped.
Thoughts about adoption:
When did you first start thinking about adoption and why? If infertility is present, explain what medical
consultation you received and your reaction then and now. Are you still pursuing medical treatment to
conceive? Describe if and how you have resolved your feelings about infertility, or if you are still
working through this process.
How do you think you will feel towards the birth parents of your child? What adoption education have
you received up to this point?
Reason for Home Study:
How were you referred to our agency? Please state your reason for completing a home study at this time.
If you are currently matched with a birth mother or are matched with a born child, please describe how
you came to be matched and/or why you wish to adopt this specific child.
Acknowledgement of Firearms Safety Requirements
Florida Statue 790.174 (safe storage of firearms required) states:
A person who stores or leaves, on a premise under his or her control, a loaded firearm, as
defined in s.790.001, and who knows or reasonably should know that a minor is likely to
gain access to the firearm without the lawful permission of the minor’s parent or the
person having charge of the minor, or without the supervision required by law, shall keep
the firearm in a securely locked box or container or in a location which a reasonable
person would believe to be secure or shall secure it with a trigger lock, except when the
person is carrying the firearm on his or her body or within such close proximity thereto
that he or she can retrieve and use it as easily and quickly as if he or she carried it on his
or her body.
I/We
and
Acknowledge that I/we have read and understand this document.
Prospective Adoptive Parent (1) Signature
Date
Prospective Adoptive Parent (2) Signature
Date
MEDICAL REPORT FOR PROSPECTIVE ADOPTIVE PARENT
Name of person examined: _______________________________________
DOB: _______________
I hereby authorize (name of medical provider) ____________________________________________________ to
release medical information contained on this form to Heart of Adoptions, Inc.
Patient’s Signature: ________________________________________________
Date: ________________
To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adults
who are applying to become adoptive parents.
PHYSICAL EXAMINATION
Height: _____________________ Weight: ______________________ Blood Pressure: ______________________
Current Medications and reason prescribed:
Medication
_________________________________
_________________________________
_________________________________
_________________________________
Reason
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
MEDICAL HISTORY
Are there any conditions that are chronic or progressive in nature that would interfere with this person’s ability to
care for a child to his/her age of majority? If so, please explain. If there are conditions that affect the patient’s
mental or emotional stability, please explain in detail: (use separate sheet if needed)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How long have you known this patient? ____________________________________________________________
Physician Certification
I certify that this patient is free from symptoms of communicable disease.
 Yes
 No
If no, please explain: __________________________________________________________
I certify that this patient has no physical or cognitive limitations that would prevent him/her from parenting.
 Yes
 No
If no, please explain: __________________________________________________________
Physician Signature: ___________________________________
Printed Name: _______________________________________
Address: ____________________________________________
Phone: _____________________________________________
Date: _______________________
MEDICAL REPORT FOR PROSPECTIVE ADOPTIVE PARENT
Name of person examined: _______________________________________
DOB: _______________
I hereby authorize (name of medical provider) ____________________________________________________ to
release medical information contained on this form to Heart of Adoptions, Inc.
Patient’s Signature: ________________________________________________
Date: ________________
To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adults
who are applying to become adoptive parents.
PHYSICAL EXAMINATION
Height: _____________________ Weight: ______________________ Blood Pressure: ______________________
Current Medications and reason prescribed:
Medication
_________________________________
_________________________________
_________________________________
_________________________________
Reason
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
MEDICAL HISTORY
Are there any conditions that are chronic or progressive in nature that would interfere with this person’s ability to
care for a child to his/her age of majority? If so, please explain. If there are conditions that affect the patient’s
mental or emotional stability, please explain in detail: (use separate sheet if needed)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How long have you known this patient? ____________________________________________________________
Physician Certification
I certify that this patient is free from symptoms of communicable disease.
 Yes
 No
If no, please explain: __________________________________________________________
I certify that this patient has no physical or cognitive limitations that would prevent him/her from parenting.
 Yes
 No
If no, please explain: __________________________________________________________
Physician Signature: ___________________________________
Printed Name: _______________________________________
Address: ____________________________________________
Phone: _____________________________________________
Date: _______________________
MEDICAL REPORT FOR CHILDREN IN THE HOME
Name of child:__________________________________
DOB: __________________
Weight: ________ Height: _________ Hair Color: _________ Eye Color: ____________
Is this child current on all immunizations: ______________________________________
Please comment on the overall health and development of this child:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How long have you known this patient? ______________________________________
Physician Signature: _____________________________________________________
Printed Name: __________________________________________________________
Address:
__________________________________________________________
Phone:
____________________________________
Date:
____________________________________
MEDICAL REPORT FOR OTHER ADULTS IN THE HOME
Name of person examined: _______________________________________
DOB: _______________
I hereby authorize (name of medical provider) ____________________________________________________ to
release medical information contained on this form to Heart of Adoptions, Inc.
Patient’s Signature: ________________________________________________
Date: ________________
To the examining physician: This report will aid Heart of Adoptions, Inc. in determining the suitability of adult
household members, residing in a prospective adoptive home.
PHYSICAL EXAMINATION
Height: _____________________ Weight: ______________________ Blood Pressure: ______________________
Current Medications and reason prescribed:
Medication
_________________________________
_________________________________
_________________________________
_________________________________
Reason
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
MEDICAL HISTORY
Are there any conditions that are chronic or progressive in nature that would interfere with this person’s ability to
be around or interact with a child? If so, please explain. If there are conditions that affect the patient’s mental or
emotional stability, please explain in detail: (use separate sheet if needed)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How long have you known this patient? ____________________________________________________________
Physician Certification
I certify that this patient is free from symptoms of communicable disease.
 Yes
 No
If no, please explain: __________________________________________________________
Physician Signature: ___________________________________
Printed Name: _______________________________________
Address: ____________________________________________
Phone: _____________________________________________
Date: _______________________