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					                  Adoption Questionnaire-                                Husband                Wife
 It is important you complete this questionnaire separately from your spouse. Your responses will be an integral part of
the adoption study. If you have any questions regarding how this information will be used or its relevance, please do not
                   hesitate to ask questions prior to completion by calling Kristal James 801-842-5904

Name                                                                                     Date
Background Information
   1. Describe your physical characteristics. Include weight, height, eye color, hair color, birth date, age, and ethnicity.

    2. Describe your personality, strengths, and weaknesses. List your hobbies.

    3. Describe your hopes, goals and aspirations.

    4. Have you ever been convicted of a felony or have a criminal history? Explain.

    5. Have you ever used or currently use drugs, alcohol or cigarettes? Explain.

    6. Share any traumatic events that have impacted your life.

Family of Origin
   7. Describe your parents including education, occupation, personality, interests, marriage(s). Include their full names,
        address and phone numbers.

    8. Explain your parents’ methods of discipline.

    9. Provide the names, ages, spouse names (including maiden) and number of children of any brothers or sisters. Also
       include your sibling’s current occupation and contact information.

Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                                 Page 1
                  Adoption Questionnaire-                                 Husband           Wife
    10. What is your present relationship with your parents and siblings?

    11. Relate any special experiences or memories.

    12. List significant activities, group involvements, or accomplishments in your life.

   13. List the location (city, county and state) of your marriage. Include the date.

    14. Describe your spouse’s personality, strengths, and weaknesses. Describe how you met and what draws you to your

    15. What leisure activities do you share with your spouse and family?

    16. How do you express love and affection?

    17. How do you feel about the intimacy in your marriage?

    18. What are the strengths and challenges of your marriage?

    19. How do you resolve conflict? What do you do? What does your spouse do?

    20. Have you ever been divorced? If yes, include former spouse’s name, date of marriage, location of marriage and
        divorce (i.e. city, county and state) and the reason for your divorce.


Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                            Page 2
                  Adoption Questionnaire-                                 Husband                 Wife
   21. Describe each child including education, personality, health, interests, strengths, talents etc.

   22. Describe how each child feels about adoption.

General Health
   23. List the name, location and phone number of your doctor(s). How long have you been a patient of his or hers?
       What are you seeing him or her for? How frequently do you see your doctor?

   24. Describe health issues you have. List current medications, diagnoses and any hospitalizations. Describe
       accommodations being made if applicable.

   25. If applicable, discuss your infertility and how it has affected you. Include information on counseling you’ve received
       or discuss how you have dealt with infertility.

   26. Is there any history of elective sterilization? (voluntary tubal ligation or vasectomy).

   27. List health issues in your extended family. Include mental health.

   28. Have you met with a mental health professional? If so, when and what were you seeing him or her for? List the
       name and contact information of your counselor (if you give permission to contact him or her).

Employment Finances and Home
   29. Describe your education, current employment and career goals. Include high school and college(s) attended.
       Include degree(s) obtained and year completed. Include a brief summary of past jobs.

   30. How do you handle family finances and major purchases?

Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                                Page 3
                   Adoption Questionnaire-                                 Husband                Wife
    31. List major debt amounts (include home, cars, credit card, student loans etc.). Do you rent or own your own home?
        List monthly mortgage, original cost of home and amount still owed.

    32. Describe your home. Include your address, square footage and year built. Also include the size of the lot, type of
        home, structural materials and any other information of importance.

    33. Do you have fire arms in the home? How are they secure? How have you safe guarded chemicals and medications?
        List any other safety precautions you have taken specific to your home.

    34. Do you have life insurance? If so, how much? Who is covered? Who is the policy through?

    35. Do you have a will drafted? Who will care for your child(ren) in the event of illness or death?

    36. Have you ever filed for bankruptcy? When?

    37. Do you have pets in the home? What kind and what breed? Are they current on their immunizations? Describe his
        or her personality.

Church and Community
   38. What is your religious affiliation? List services you provide in your religious organization if any.

    39. List the past and present involvement with community organizations.

    40. Describe your neighborhood and local schools.

Parenting Methods and Discipline
    41. Do you intend to use corporal punishment? Explain

Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                                Page 4
                 Adoption Questionnaire-                                 Husband                Wife

   42. Please describe your discipline method(s). What is your belief and philosophy on raising children?

   43. How many children do you plan to adopt?

   44. What are your thoughts about birth moms? Dads?

   45. Please describe your thoughts regarding prospective adopted child(ren). Include thoughts about ethnicity, gender,
       birth parent history of substance or alcohol use, mental health history, etc.

   46. Please describe your desires for adoption openness. Are you willing to meet with the adoptive mother prior to
       placement? Are you willing to write letters and provide pictures through the agency for the birth mom for one
       year? Are you willing to provide information more or less frequently?

   47. Do you plan to facilitate cultural awareness for your adopted child if the child is of a different ethnicity? How do
       you plan to do this?

   48. How do you plan to tell your child he or she is adopted? When?

   49. Are you willing to sign the adoption registration?

   50. Do you have any questions regarding the adoption process?

Miscellaneous *Note, you do not need to have all these completed prior to my visit with you in your home; however, the
highlighted ones will be necessary to finalize the home study.
    51. Have you turned in your background checks (BCIs)?

Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                                 Page 5
                    Adoption Questionnaire-                              Husband               Wife
    52.   Have you submitted a copy of your birth certificate for you, your spouse and children?
    53.   Have you submitted a copy of your marriage license?
    54.   Have you submitted a copy of your divorce decree(s) if applicable?
    55.   Have you submitted a copy of the first page of your last three years of tax returns?
    56.   Have you submitted three reference letters? List the names and contact information for each reference. Also
          include how you know him or her and for how long.

   57. Have you submitted a copy of the current immunizations for any pets in the home?
   58. Have you submitted a copy of the Understanding of Utah Adoptive Home Preplacement Evaluation? *This is
       necessary prior to my visit to your home.
   59. Have you submitted your profiles?
   60. Have you submitted your medical evaluation?
   61. Have you submitted a copy of your driver’s license?
   62. Have you submitted a copy of your social security card?
   63. Have you submitted your adoption registry form?
   64. Are you aware there are children currently waiting for adoption through the state of Utah? Would you like more
   65. Have you ever been denied a homestudy? If so, when?
   66. Have you submitted a copy of your medical insurance card?
*Payment for the homestudy is due in full at the time of service.

Thank you for taking time to complete this questionnaire. Please feel free to submit it electronically, or provide me with
a hard copy at the time of the homestudy visit. I look forward to meeting you.

Beacon Counseling and Consulting PO Box 160701, Clearfield, UT 84016 (801) 842-5904                                 Page 6