Confidential Disclosure Sheet – A Giving Tree Adoptions Inc.

Adoptive Parent 1 *

First

Last

Have you ever had a drug/alcohol problem?

Have you been a victim of abuse? (disclosed or undisclosed)

Have you ever been charged with and/or investigated for child abuse?

Have you ever been arrested, charged or investigated with a crime or felony of any kind?

Have you had a criminal conviction? (court disposition must be obtained for any incident)

Have you been turned down by an adoption agency?

Have you had a previous home study completed?

Have you filed for divorce, dissolution, legal separation or annulment of present marriage?

Have you ever seen a counselor/minister for any reason?

If your answer is “yes” on any of the above questions, please explain.

Please list all prior home studies identifying the following for each: 1. Name and contact information of agency previously used; 2. Date of completion or termination of prior home studies; 3. Reason for termination, if applicable; 4. Outcome of previous adoption or child fostering.

Adoptive Parent 2 *

First

Last

Have you ever had a drug/alcohol problem?

Have you been a victim of abuse? (disclosed or undisclosed)

Have you ever been charged with and/or investigated for child abuse?

Have you ever been arrested, charged or investigated with a crime or felony of any kind?

Have you had a criminal conviction? (court disposition must be obtained for any incident)

Have you been turned down by an adoption agency?

Have you had a previous home study completed?

Have you filed for divorce, dissolution, legal separation or annulment of present marriage?

Have you ever seen a counselor/minister for any reason?

If your answer is “yes” on any of the above questions, please explain.

Please list all prior home studies identifying the following for each: 1. Name and contact information of agency previously used; 2. Date of completion or termination of prior home studies; 3. Reason for termination, if applicable; 4. Outcome of previous adoption or child fostering.

Signatures

I hereby certify that the above information is true and complete to the best of my knowledge and agree to notify A Giving Tree Adoptions of any changes regarding any of these issues.

Adoptive Parent 1 Signature *

Date *

Adoptive Parent 2 Signature

Date