The Adoption Consultancy: Domestic and International Adoption Guidance

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 .pdf and text based formatting: .pdf .txt

You may then mail the completed form to:

The Adoption Consultancy
809 E. Bloomingdale Ave.
Suite 388
Brandon, FL 33511

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:

Adopting Mother’s Information*:
Date of Marriage:
Name (Last, First):
Work Phone:
Cell Phone:
Email:
Work Fax:
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 Father’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 will range from $10,000 to $35,000. 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?
.
* For single and/or gay applicants, please adjust the format of the information as needed.
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