Welcome to Special Angels Adoption!
We are excited that you are considering adopting a baby or toddler with special
needs. In order to best match you to available adoption situations, we need you
to fill out the following information as accurately as possible. This intake form will
be kept confidential and will not be shown to Birthfamilies, other adoptive
parents, or agencies, so you can be completely honest. Once the match is made
adoptive families will be given the contact information of the adoption agency or
attorney.
All the children currently in your home must have finalized adoptions or be your
legal foster children for us to be able to work with you. Your homestudy must be
current and we must be able to contact your social worker in order to add you to
our list of prospective adoptive parents. Please let your social worker know we
will be contacting them shortly after receiving your intake form.
Would you like to put your photo and first names on our website as a family
hoping to adopt a special needs child? If so please email us a picture and a short
paragraph about your family and sign in the appropriate space at the bottom of
this form.
A huge part of our success is word of mouth referrals, and we desperately need
the help of families like you to get the word out about our website. Please
consider including a link to our website on your blog, telling any adoption
agencies you may come in contact with about us, and spreading the word about
Special Angels Adoption as much as possible. By helping us, you will help increase
your own exposure to potential adoption situations. Thank you!
Feel free to email any questions: Sara@specialangelsadoption.org, or
Jennifer@specialangelsadoption.org
Special Angels Adoptions Adoptive Parent Intake Form
(All information is required. Do not skip any area)
Date:
Parent One’s Full Name:
Parent One’s Birth Date:
Parent Two’s Full Name:
Parent Two’s Birth Date:
Street Address:
City, State, Zip Code:
Phone Number(s):
Email Address:
Married:
Y/N
Length of Marriage:
Any Divorce History:
Y/N
Which Spouse: Parent One/Parent Two
Any Criminal History:
Y/N
Which Spouse: Parent One/Parent Two
Race of Parent One:
Race of Parent Two:
List your current children, their ages, their races, and whether or not they were
adopted.
Tell us about your experience with special needs populations (in less than 400
words):
Link to on-line adoption profile:
(On-line profile not required but PFD one is)
Race(s) you are open and approved to adopt:
Caucasian
African American
Hispanic
Asian American
Indian Pacific Islander
Mixed Race
Age range you are open to adopting:
Gender(s) you wish to adopt:
Male
Female
Adoption Budget Range: $
Please indicate the special needs you are educated about, open to, and approved
to adopt:
Down Syndrome
Turner Syndrome
Other Congenital Abnormalities
Blindness
Deafness
Missing or Deformed Limbs
Other Physical Deformities
Respiratory Difficulties
Heart Defects
Cerebral Palsy
Dwarfism
Digestive Trace Problems
G-tube
Wheelchair Bound
Significant Developmental Delays
Significant Physical Delays
Kidney Issues
Neurological Damage
Genetic Mental Health Issues
Cleft Lip and/or Palate
Club Foot
HIV
Hepatitis
Hormone Disorders
Surgeries Needed
Preemie
Mute or Delayed Speech
Little to No Immune Function
Abused
Hydrocephaly
Significant Exposure to Alcohol and/or Drugs
Other, please describe:
Homestudy Completion Date:
Expiration Date:
Are you approved for special needs children under the age of 3?
Y/N
Social Worker or Agency’s Name:
SW/A Phone Number:
SW/A Email Address:
Permission to Contact Social Worker (required)
We, _________________ and _______________ give permission for a
representative of Special Angels Adoption to contact our social worker or agency,
_________________, to validate our homestudy, confirm our ability to adopt a
special needs child, and gather/share other information as needed.
______________________________
_____________________________
Parent One signature and date
Parent Two signature and date
(You cannot join Special Angels Adoption without a valid homestudy. If you do not
give permission above we cannot allow you to join.)
Permission to Share Profile, and Contact Information (required)
We, _________________ and _______________ give permission for a
representative of Special Angels Adoption to share our profile (not this intake
form) with potential birth families, adoption agencies, and adoption lawyers for
the purposes of potentially being matched with a birth family on situations we
express an interest in. We give permission to share our contact information if
required to complete the match – such as to arrange a phone conference for the
birth family to gain additional information before choosing an adoptive family.
We understand that Special Angels Adoption agrees to share information as
related only to potential adoption situations we have asked to be presented to.
We also agree to hold Special Angels Adoption and its representatives harmless of
any consequences that might occur as a result of sharing this information. Special
Angels Adoption does not have control over what will happen with such
information once it leaves their possession.
______________________________
_____________________________
Parent One signature and date
Parent Two signature and date
Permission to Post Public Profile (optional)
We are submitting our picture and paragraph-long introductory profile to Special
Angels Adoption with the intent that the information be posted on their webpage
for viewing by potential Birthfamilies and agencies, as well as the general public.
We understand that information shared over the internet is public. We
understand that while we can request at any time that Special Angels Adoption
remove the information, once information is shared on the internet, there is no
guarantee that the information can be completely deleted from the internet. Our
signature below indicates our understanding and permission to post our profile.
______________________________
_____________________________
Parent One signature and date
Parent Two signature and date
_____ (Initial here if you are opting out of this program)
Confidentiality Notice (required)
ALL INFORMATION SHARED AS PART OF SPECIAL ANGELS ADOPTION IS SUBJECT
TO STRINGENT CONFIDENTIALITY. SHARING INFORMATION OUTSIDE OF THE
GROUP IS STRICTLY PROHIBITED. PERSONS FOUND DOING SO WILL BE REMOVED
FROM THE GROUP AND HAVE THEIR SOCIAL WORKER CONTACTED ABOUT THE
VIOLATION.
Please sign below indicating you understand and agree to this policy.
______________________________
_____________________________
Parent One signature and date
Parent Two signature and date
Please sign and date in all places indicated. Electronic signatures are accepted for
30 days ONLY. You can return a scanned document to
intakeforms@specialangelsadoption.org. If you do not have access to a scanner,
please email a copy and then send a hard copy within the 30-day window. Mail to:
Sara Deaterla, c/o Special Angels Adoption, 77 Russ Rd., Jackson, Ohio 46540 or
Fax to: 1-740-422-1675.
Please rename this file as follows when emailing:
LastNameStateYear Intake Form
*Example:KellyAL2013 Intake Form
Once we receive this form and can validate your homestudy, you will be approved
to join the discussion board. The invitation for the discussion board will be sent to
the email address you have listed above. You will receive emails (via the Special
Angels Adoptions Yahoo Group) about our adoption situations as they arise. If
you are interested in pursuing a specific adoption situation, please let us know
ASAP by completing the “Adoption Situation Interest Form” for that situation.
There may be more than one family interested, and the final decision is up to the
Birthfamily or the agency handling the adoption.
Thank you very much and welcome to Special Angels Adoption!