Adoptive Family Questionnaire

When we turn our profile in, we are also required to turn in this questionnaire.  This is the document the agency will use when deciding whether or not to show our profile to prospective birth parents.  Matt and I need to have some uninterrupted time to have a final discussion on what we are comfortable with in terms of our future child and their race, medical background, and legal issues.

If you have not looked into adoption much, it is a lot to think about and put on paper.  If you are baby making with your spouse, you don't have to check yes or no each time to potentially getting pregnant.  Being comfortable with situations that are not under your control can be very intimidating.

The AFQ asks the following questions:
Age you are open to welcoming- (even though our agency is an infant program)
Number of children you would consider:
Full siblings?
Half-siblings?
If birthmother returns to the agency, to relinquish a child by a different father, are you open to being contacted?
Open to the following racial backgrounds- yes or no
Caucasian
Caucasian/ Unknown
Caucasian/ Native American
Caucasian/ Asian/ Pacific Islander
Caucasian/ Hispanic
Caucasian/ African American
African American
African American/ Native American
African American/ Asian/ Pacific Islander
African American/ Hispanic
Native American
Native American/ Asian/ Pacific Islander
Native American/ Hispanic
Asian/ Pacific Islander
Asian/ Pacific Islander/ Hispanic
Hispanic

Are you open to being contacted with little to none known about the identity, whereabouts, or family history or the:
mother?
father?

Drug & Alcohol Usage
Choices are Yes, we feel comfortable   Maybe, please call with situation   No, do not show profile

We must write a choice in each box for used 1-5 times during first trimester, Used monthly during pregnancy, Used weekly during pregnancy, Used daily during pregnancy in the following categories:

Cigarettes
Alcohol
Marijuana
Methamphetamine
Heroin
Ecstasy
Methadone
LSD
Drug stimulants
Depressants
Tranquilizers
Cocaine

Child's Background- select could accept, could not accept, or willing to discuss:
How Birth Mother Became Pregnant:
extramarital affair
prostitution
rape
incest
unknown father
2 or more named fathers

Prenatal History:
Limited prenatal care
no prenatal care
child is premature

Medical History:
Mother:
diabetes
epilepsy
below average IQ
learning disabilities
personal history of chronic mental illness
family history of chronic mental illness
history of additcion

Same as above for father's side