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The Applicants applied to become an Adoptive Family placement of a male or female child between the ages of
Age and Age from the country of at time of referral.
The Applicants Select One open to the placement of a sibling group. If open to a sibling group,
how many?
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Race: Race:
Ethnic Origin: Ethnic Origin:
Tribal Affiliation: Tribal Affiliation:
Education: Education:
Citizenship (what country?): Citizenship (what country?):
Alien Registration Number (if required): Alien Registration Number (if required):
Language(s): Language(s):
Occupation: Occupation:
Employer: Employer:
Annual Gross Income: Annual Gross Income:
Sources of Additional Income: Sources of Additional Income:
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>> REFERENCES
Name Relationship to Applicants Date Received
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The references have known Steven and Allison between 5 and 13 years. All three references were positive and
strongly agree that Steven and Allison are capable of providing love and security to any child. Steven is seen as
outgoing, honest, and friendly while Allison is described as active, happy, and compassionate. Both Steven and
Allison are seen as supportive, hardworking, and responsible. The references stated Steven and Allison are in a
strong, loving and stable marriage. One reference stated Steven and Allison have always been respectful,
responsible, and fun with children another reference stated Steven and Allison have lots of experience with
children and are great with them All three references would feel very comfortable allowing Steven and Allison
to care for their children if they were unable to do so.
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>> MOTIVATION
[--Indicate whether or not the Applicants have any adoption experience and the response of each adult member of
the household as to whether he/she has ever been approved, rejected or deferred as a prospective adoptive parent, or
has been the subject of an unfavorable home study with any child placing agency.--]
[--Physically describe each child/youth involved in the home study: name, sex, age, date of birth, height, weight,
eye, and hair color.--]
[--For each child/youth currently in the home, discuss their adjustment since placement. If not currently placed
with the Applicants discuss the nature and character of the Applicants relationship(s) with the child(ren) or
youth(s).--]
[--Describe the strengths, personality, interests, and emotional/physical development of each child or youth being
considered in the home study.--]
[--Discuss the level of understanding each child/youth has about such issues as reunification, maintaining
connections, adoption, etc. --]
The Applicant was asked if he/she had ever applied or attempted to adopt before this time or if they have ever been
the subject of an unfavorable home study report or rejected as a potential adoptive parent. The Applicant was also
asked about any history of alcohol or substance abuse, sexual abuse, child abuse, family violence or criminal
history, even if it did not result in an arrest or conviction either as a victim or perpetrator, in the United States or
abroad. The Applicant states that they have no history of these problems and has never been arrested, detained or
convicted of a crime in the United States or abroad. The Applicant was asked if Immigration ever refused them a
VISA clearance and they stated no.
The Applicant was asked if he/she had ever applied or attempted to adopt before this time or if they have ever been
the subject of an unfavorable home study report or rejected as a potential adoptive parent. The Applicant was also
asked about any history of alcohol or substance abuse, sexual abuse, child abuse, family violence or criminal
history, even if it did not result in an arrest or conviction either as a victim or perpetrator, in the United States or
abroad. The Applicant states that they have no history of these problems and has never been arrested, detained or
convicted of a crime in the United States or abroad. The Applicant was asked if Immigration ever refused them a
VISA clearance and they stated no.
[--Describe the home and community so that a reader can picture the home and the surrounding community. This
should be a strength-based description pointing out what makes the home unique to the Applicants (special
decorations, color schemes, projects, etc.) Indicate whether the home meets state requirements. --]
[--Describe the neighborhood as well as the community surrounding the residence and focus on resources in the
area: hospitals/specialized medical providers, schools, special education programs, places of worship, mental health
services, etc.--]
[--Describe the Applicants physical appearance: height, weight, hair and eye color, striking physical attributes.
Describe how the Applicant presents himself/herself assured, hesitant, physically active, sedate, thoughtful, etc.
Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, describe what
the Applicant shared regarding his/her aspirations and goals in life. You may also include something their
spouse/partner has said about them that describes their personality.--]
[--Describe the Applicants physical appearance: height, weight, hair and eye color, striking physical attributes.
Describe how the Applicant presents himself/herself assured, hesitant, physically active, sedate, thoughtful, etc.
Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, describe what
the Applicant shared regarding his/her aspirations and goals in life. You may also include something their
spouse/partner has said about them that describes their personality.--]
[--This is your opportunity to introduce this family to the home study reader.--]
[--Describe typical work and non-work day routines and rituals. Describe how the Applicants feel their routines
and rituals will or have changed with the placement of a child or children.--]
[--What are the basic household rules, roles, and expectations? Who does what in terms of chores, cooking, bill
paying, home maintenance, transportation, etc.? --]
[--Describe what recreational, cultural, social, and/or religious activities the Applicants participate in. --]
[--If the Applicants have pets describe them. Who is responsible for pet care? Who ensures their well-being
(vaccinations, checkups)?--]
CHILD CARE
[--Describe current and proposed childcare arrangements. Who will be or has been designated their substitute
caregiver? What is his/her relationship to the Applicants? What measures have been or will be taken to assure that
substitute caregiver(s) is responsible and sensitive to a childs needs? What are the Applicants short and long-term
emergency substitute childcare plans?--]
PRIVACY
[--Describe the sleeping arrangements and how the family deals with privacy and nudity in the home. Describe
how they have or will modify this behavior with/since the placement of children in the home.--]
The Applicant(s) have been provided with information concerning the different roles, responsibilities, legal and
financial rights and benefits of international adoptive parents.
The agencys complaint procedures [--have/have not--] been explained to the Applicants.
[-- Provide a one paragraph narrative describing the Applicant's history: where and when they were born, who they
were born to, siblings, schooling, marriages, civil unions, domestic partnerships, deaths, divorces, etc. Do not
include issues you have identified in the Psychosocial Inventory with SAFE Desk Guide Ratings. This is a factual
description of the Applicant's history. --]
Referrals were not made to mental health resources as the practitioners professional assessment that none were
needed based on the Applicants current functioning and the fact that they did not have any significant issues
related to any past history of illness, or any mental, emotional, psychological, or behavioral instability. If mental
health resources.
Special Instructions: If referrals were made to mental health resources please delete the above section and discuss
in the Psychosocial Evaluation (see below).
EVALUATION
[--Follow Evaluation Instructions--]
[--If referrals were made to mental health resources for further mental health evaluation during the home study,
indicate that the evaluation conclusions and specific issues that required further evaluation using Psychosocial
Narration Instructions (page 1)--]
[--If Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical
reasons for which they are being taken.--]
EVALUATION
[--Follow Evaluation Instructions--]
[-- Provide a one paragraph narrative describing the Applicant's history: where and when they were born, who they
were born to, siblings, schooling, marriages, civil unions, domestic partnerships, deaths, divorces, etc. Do not
include issues you have identified in the Psychosocial Inventory with SAFE Desk Guide Ratings. This is a factual
description of the Applicant's history. --]
Referrals were not made to mental health resources as the practitioners professional assessment that none were
needed based on the Applicants current functioning and the fact that they did not have any significant issues
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related to any past history of illness, or any mental, emotional, psychological, or behavioral instability. If mental
health resources.
Special Instructions: If referrals were made to mental health resources please delete the above section and discuss
in the Psychosocial Evaluation (see below).
EVALUATION
[--Follow Evaluation Instructions--]
[--If referrals were made to mental health resources for further mental health evaluation during the home study,
indicate that the evaluation conclusions and specific issues that required further evaluation using Psychosocial
Narration Instructions (page 1)--]
[--If Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical
reasons for which they are being taken.--]
EVALUATION
[--Follow Evaluation Instructions--]
[--Provide a brief description of the Applicants Marriage/Domestic Partnership highlighting their roles in the
relationship, division of duties, strengths and skills.--]
EVALUATION
[--Follow Evaluation Instructions--]
[--Is the minors behavior age-appropriate? Does the minor present any health, developmental, educational or
mental health issues? How secure, well adjusted, and adaptable is the minor? Are his/her needs being well met?
Does the minor exhibit any behaviors that pose a threat to the health, safety, and well-being of self or others? Does
the minor have a secure attachment to both his/her parents? Does the minor have any alcohol or drug involvement?
How prepared is the minor for the arrival of a new child into the family?--]
EVALUATION
[--Follow Evaluation Instructions--]
[-- Is the minors behavior age-appropriate? Does the minor present any health, developmental, educational or
mental health issues? How secure, well adjusted, and adaptable is the minor? Are his/her needs being well met?
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Does the minor exhibit any behaviors that pose a threat to the health, safety, and well-being of self or others? Does
the minor have any alcohol or drug involvement? How prepared is the minor for the arrival of a new child into the
family?--]
EVALUATION
[--Follow Evaluation Instructions--]
[--How positive and supportive is he/she about having a new child come into the family? How much and how
frequently does he/she consume alcohol? Does he/she use illegal drugs or abuse prescriptive/over-the-counter
drugs? How well does he/she accept differences? Does he/she exhibit responsible behavior and emotional
stability? Does he/she exhibit any behaviors that pose a threat to the health, safety, and well-being of self or
others? Does he/she have a history of criminal arrests, convictions, or allegations of child sexual/physical abuse,
child neglect, child exploitation, or failure to protect?--]
EVALUATION
[--Follow Evaluation Instructions--]
[--How positive and supportive is he/she about having a new child come into the family? How much and how
frequently does he/she consume alcohol? Does he/she use illegal drugs or abuse prescriptive/over-the-counter
drugs? How well does he/she accept differences? Does he/she exhibit responsible behavior and emotional
stability? Does he/she exhibit any behaviors that pose a threat to the health, safety, and well-being of self or
others? Does he/she have a history of criminal arrests, convictions, or allegations of child sexual/physical abuse,
child neglect, child exploitation, or failure to protect?--]
EVALUATION
[--Follow Evaluation Instructions--]
[--Describe if and how the extended family is positive regarding the Applicants desire to adopt. Has anyone in the
extended family had any experience as an adoptive parents?--]
EVALUATION
[--Follow Evaluation Instructions--]
[--Describe if and how the extended family is positive regarding the Applicants desire to adopt. Has anyone in the
extended family had any experience as an adoptive parents?--]
EVALUATION
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[--Finances: [--Place special emphasis on this factor by addressing each of the Desk Guide criteria that apply even
if the Final Desk Guide Rating is a 2. Describe the Applicants; income, financial resources, debts and expenses.
State the evidence that was considered to verify the source and amount of income and financial resources. Is the
family income and financial resources sufficient to meet family needs? Clarify that any income designated for the
support of children in the care and custody of the Applicants or any income used for support of any other member
of the household is not used for purposes of evaluating income and finances. Are the Applicants able to budget,
organize and spend money wisely? Do the Applicants have adequate resources available for emergencies?--]
[--Safety: Provide the information that your regulations, rules and statutes require pertaining to the residence such
as swimming pool/fountains, other water features, guns, trampolines etc. Please provide the Safety Plan if
appropriate. Describe all pets and discuss their comfort level with children. Indicate if anyone in the household
smokes and if so indicate the designated smoking areas --]
EVALUATION
[--Follow Evaluation Instructions--]
[--How were the Applicants disciplined as a child and how does that impact the way they discipline their children
and/or will discipline any future children? What kind of discipline do the Applicants intend to use? Do the
Applicants have good knowledge of appropriate and effective forms of discipline?--]
Bring together the ratings of the Applicants and describe how they would parent a child with few or no issues.
EVALUATION
[--Follow Evaluation Instructions--]
[--Special Narration Instruction for H-4, Effects of Separation and Loss: Place special emphasis on this factor
by providing full narration that relates to each of the Desk Guide criteria that apply even if the Final Desk Guide
Rating is 2. Your narration needs to expand upon the Applicants ability to address the unique separation and loss
issues inherent in international adoption such as the effects of institutionalization on children, abandonment, lack of
opportunity for pre-placement visits, language barriers and child adjustment challenges.
[--Special Narration Instruction for H-6, Therapeutic and Educational Resources: Place special emphasis on
this factor by providing full narration that relates to each of the Desk Guide criteria that apply even if the Final
Desk Guide Rating is 2. Your narration needs to expand upon the Applicants readiness to address the challenges
inherent in international adoption that result from a lack of medical and social background information and the
heightened risk of developmental delays.
[--Special Narration Instructions for H-10, Cross Cultural Issues: Place special emphasis on this factor by
providing full narration that relates to each of the Desk Guide criteria that apply even if the Final Desk Guide
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Rating is 2. Your narration needs to evaluate whether or not the Applicants are ready, willing and able to parent a
child of a different race or culture and ensure that the childs heritage and cultural identity will be honored and
embraced--]
EVALUATION
[--Follow Evaluation Instructions--]
[--Maintaining Connections with Birth Families: Do the Applicants understand and accept the importance of
maintaining birth family connections for a child who has been adopted? Are they secure in their parental role as
adoptive parents and ready, willing and able to support contact with birthparents and other significant connections
such as siblings and grandparents based on the best interest of the child? Are the Applicants willing to be involved
in family visits, family team meetings, and working as a team member to meet the permanency goal for a child?--]
[--Special Narration Instructions for I-4, Adoptive Parent Status: Place special emphasis on this factor by
addressing the following. Summarize the counseling given to prepare the prospective adoptive parents for an
international adoption and any plans for post placement counseling. Verify and record that this pre-adoption
counseling included a discussion of the processing, expenses, difficulties and delays associated with international
adoptions. Verify and record that the Applicants understand the importance of and have agreed to post-placement
and post-adoption reporting requirements as required by their childs state or country. Verify and record the
Applicants agreement and willingness to cooperate with the social worker in the developing these reports. If
applicable, verify that the family is up to date on any current post placement reports for past adoptions. --]
EVALUATION
[--Follow Evaluation Instructions--]
Please reference the information sheet on the country in question and include any additional information that the
country might require.
[--Discuss each of the strengths and concerns you have covered earlier in the home study. Please make a
determination how each issue together and separately could or does affect the Applicants current functioning or
ability to parent.--]
>> RECOMMENDATION
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It is recommended that the International adoption home study for Applicant 1 Full Name and Applicant 2 Full
Name be Choose an item..
[--If this report is favorable, summarize the reasons for such approval. Include the number of children that the
prospective adoptive parents may adopt. State whether there are any specific restrictions such as nationality, age
or gender of the child. If the prospective parents are approved for a h or special needs adoption, clearly state the
fact.--]
>> ATTESTATION
I certify that I am authorized by the laws of the State of [-State-] (Insert Citation to Applicable State law) to
prepare home studies. In accordance with 9CFR 204.311(f) I declare under penalty of perjury under U.S. law that I
personally and with due professional diligence reasonably necessary to protect the best interest of any child whom
the Applicants might adopt, either actually conducted or supervised this home study (interviews, home visits and
other necessary investigations) or if I did not, the following individual did so as indicated below:
[-Name-]
[-Agency-]
[-Agency Address -]
[-Telephone Number-]
[-E-mail Address-]
The factual statements in this home study are true and correct to the best of my knowledge, information and belief.
I have advised the Applicants of their duty of candor under paragraph d of this section, specifically noting the
ongoing duty of disclosure of new events of information, and the consequences should they fail to disclose any
information.
The home study is a true and accurate copy of the home study that was provided to Immigration and has been
reviewed by the Applicants.
This home study was prepared for International adoption in accordance with such standards and in accordance with
the standards and requirements that apply to a domestic adoption in the State of [-State-]. The Applicants actual
State of residence or with those in the Applicants proposed State of residence. I am authorized to conduct
Convention home studies by virtue of my status or employment. My status is: Choose an item.
OR
Prepared by Worker Name, Credentials, who is authorized by the State of [-State-] under the Rules Regulating
Child Placement Agencies to research and prepare home studies and is employed by [-Agency Name and license
number-]. [-Agency Name-] is a supervised provider for [-contracted Hague agency-], based on a signed agreement
executed on [-date of contract between agencies-]. In accordance with 22 CFR Part 96 [-Hague Accredited agency
and license number -] is an accredited agency on file with the United States Department of State as having authority
to conduct Convention home studies.
This home study will be submitted to the designated agency who has the contract authority with the State of [-
State-] to review and approve international home studies completed in [-] by licensed child placement agencies.
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