PREPLACEMENT ASSESSMENT CHECKLIST
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Prospective Adoptive Parent(s) Name(s)
Identification Number
Social Worker
Date
DIRECTIONS: Indicate whether the information listed below has been included in the Preplacement Assessment.
Information Included in
Preplacement Assessment
YES
NO
N/A
1. Was Preplacement Assessment completed within 90 days of acceptance of request?
2. Was at least one personal interview and separate face-to-face interviews held with each member of the
household above six years of age?
3. If the Preplacement Assessment was completed 18 months or more before placement of a child occurs was it
updated to reflect current information about the family?
4. Are physical examinations of family members current to within 12 months of the Preplacement Assessment?
5. Has the following areas been assessed and the information documented in the adoptive applicant’s record:
(a) the applicant’s reasons for wanting to adopt?
(b) the strengths and needs of each member of the household?
(c) the attitudes and feelings of the family, extended family and significant others involved with the family
toward accepting adoptive children and parenting children not born to them?
(d) the attitudes of the applicants toward the biological parents and in regards to the reasons the child is in
need of adoption?
(e) the applicant’s attitude toward the child’s behavior and discipline?
(f) the applicant’s plan for discussing adoption with the child?
(g) the emotional stability and maturity of applicant?
(h) the applicant’s ability to cope with problems, stress, frustrations, crisis, and loss?
(i) the applicant’s ability to give and receive affection?
(j) the applicant’s child-caring skills and willingness to acquire additional skills needed for the child’s
development?
(k) the applicant’s ability to provide for the child’s physical and emotional needs?
(l) whether the applicant’ has been convicted of a crime other than a minor traffic violation?
(m) a statement regarding the results from criminal record checks of household members over the age of
eighteen?
(n) the applicant’s physical and mental health, including and any addiction to alcohol and drugs?
(o) the strengths and needs of birth children or previously adopted children?
(p) the current financial information provided by the applicant, including property and income?
(q) the applicant’s personal character references?
(r) the location and physical environment of the home?
(s) the applicant’s religious orientation, if any?
(t) the plan for child care, if parents work?
(u) recommendations for adoption in regard to the number , age, sex, characteristics, and special needs of
children who could be best served by the family?
Information Included in
Preplacement Assessment
YES
(v) any previous request for a Preplacement Assessment or involvement in an adoptive placement and the
outcome of the Preplacement or placement?
(w) whether the individual has ever been a respondent in a domestic violence proceeding or a proceeding
concerning a minor who was allegedly abused, neglected, or delinquent, and the outcome of the
proceeding?
(x) whether the applicant has located a parent interested in placing a child for adoption with the applicant, and a
brief, non-identifying description of the parent and the child?
(y) the applicant’s age, date of birth, nationality, race or ethnicity, and any religious preference:
(z)
the applicant’s marital and family status and history, including the presence of any children born to or
adopted by the applicant, and any other children in the household?
(aa) the applicant’s educational and employment history and any special skills?
(bb) any additional facts or circumstance that may be relevant to a determination of the applicant’s suitability to
be an adoptive parent, including the quality of the home environment and the level of functioning of any
children in the household?
(cc) If any of the information listed is not reasonably available, does the Preplacement Assessment state why
the information is unavailable?
5. Has the Preplacement Assessment been prepared and typed for review by the agency’s adoption review
committee?
6. Has the Certification of Adoption Preplacement Assessment been completed?
7. Has the Preplacement Assessment been included in the applicant’s permanent record?
8. Once the agency has made a decision regarding the suitability of he applicant as an adoptive placement, does
the Preplacement Assessment include specific documentation of the factors which support that determination?
9. If the agency determines that the applicant is not suitable to be an adoptive parent, does the Preplacement
Assessment include specific documentation of the factors which support the determination?
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NO
N/A
Certification of Adoption Preplacement Assessment
I, _______________________________, Director/Designee of ____________________________
Print Name of Director or Designee
Adoption Agency
do hereby certify that the foregoing __________ pages of the attached Preplacement Assessment
number of pages
constitute a true and accurate copy of the Preplacement Assessment prepared for:
______________________________________________
Print Name of Prospective Adoptive Parent(s)
on the ______ day of ________________________, _______, and was approved by this agency
(day)
(month)
(year )
on the ________ day of __________________, _______.
(day)
(month)
(year )
______________________________________________
Signature of Agency Director or Designee
I certify that I, the undersigned, am a Notary Public or one otherwise empowered to acknowledge
signatures under Chapter 47 of the General Statutes of North Carolina.
Witness my hand and seal this day the _________________ day of _________________, ________.
(day)
(month)
Signature _____________________________________
Title
_____________________________________
My commission expires ___________________________
(year )