Apply Online - Domestic

Applicant Info
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip Code:
Email:
Phone:
Date of current marriage:
Date of birth:
Place of Employment:
Employment address:
Employment phone:
Employment fax:
Occupation:
Annual Income:
Amount in savings:
Social Security No:
Number of divorces:
Last date divorced:
Any medical diagnoses:	Yes \| No
Any mental health history use additional pages if necessary
Medications:
Criminal convictions:
Arrests:
Religious affiliation:
Children: This includes all children in the family, whether or not living in the home, regardless of age, and from all previous marriages
Ethnic back ground
Type of Adoption:

Spouse Info
Last Name:
First Name:
Middle Name:
Date of birth:
Place of Employment:
Employment address:
Employment phone:
Employment fax:
Occupation:
Annual Income:
Amount in savings:
Social Security No:
Number of divorces:
Last date divorced:
Any medical diagnoses:	Yes \| No
Mental health history:
Medications:
Criminal convictions:
Arrests:
Religious affiliation:
Children: This includes all children in the family, whether or not living in the home, regardless of age, and from all previous marriages
Ethnic back ground
Type of Adoption:


General Info
Do any others live in the home with you?	Yes \| No
If yes, describe relationship

Do you currently have a home study completed or in process?
Name of agency:
Address and phone:
Caseworker: (Name, email address, phone number)
Have you ever been denied approval for a home study?	Yes \| No
Aside from the previous question, have you ever been rejected as an adoptive or foster parent?	Yes \| No
If yes, please explain:

Are you working with any other resource besides BHAS? Yes \| No
If yes, please tell us about that resource:
Name
Address
Phone

Does either applicant have any history of substance abuse as indicated by counseling, treatment, arrest or conviction? Yes \| No
Is there any history of mental illness or treatment for mental illness at any time in the past? Yes \| No
Is either applicant taking any medication? Yes \| No
If so, list medications and the reason it was prescribed
Has either applicant completed any pre-adoptive educational training at this time? Yes \| No
If so, describe such training, who provided it, how many hours, class/online, etc.
Briefly state why you wish to adopt a child domestically.
Have you attended any informational seminars on adoption? Yes \| No
If yes, where and when?
What is your adoption budget?
Photo of Adoptive Couple

By signing this application I/we authorize BHAS to obtain information about me/us from any and all resources listed above and from all adoption agencies or home study agencies that are now or have in the past provided services to me/us. I/We agree that BHAS is authorized to maintain and display my/our information on BHAS premises, and to provide and share confidential information to my/our home study agency.

I/we understand that laws and regulations of the foreign governments and agencies in countries where BHAS maintains programs may change without notice; that adoptions in any country may be delayed, suspended or terminated at any time without notice; and that consequently, I/we may be subject to changing requirements and/or programs for international adoption. I/we agree that a photocopy of this authorization is as valid as the original.

I/we understand that this application is preliminary in nature and as such application does not guarantee acceptance into a particular program; applicants must meet program criteria as provided by the foreign country or the agency.

I/we further state that to the best of our knowledge, information and belief, all of the information contained in this application is true. I/we understand that in the event that we have misrepresented information to BHAS, our adoption process may be terminated immediately and all fees shall be due immediately.

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