WPC  27K [uU ..ˤDg7I@,v 6VFLXZ[~l:^Md#\=9O4]ۜ p8rmG@twjZ σK"82s;(cJ+{Y񞻔:Ar_zp@k&G fi)!~j8al [1.h"ӑ< Iȼpm Vbj@eXToS|=>$5"4^)bX/{$ d{Tu?WgyٶG@F2tkuf}J|(/yhm xP1HYk_\rIT|L_bZOnuݪ6m3Jϒu7< M^>na KLs$(`bDxQc#UN % 0(w4( m*UHANUD^ Canon PIXMA iP6000D0**00(9 Z6Times New Roman RegularX($ 1:i+003|xU* 0Times New Roman Bold"  Z,Invitation RegularY 2 !  _  8XXdd8 XCXXXX ?iX XCXLifeFocusCenter  2211So.HaciendaBlvd.,Suite103C ( HaciendaHeights,CA.91745 < 6263307990  P Dr.ElaineKindle,Ph.D.,_LCSW_,BoardCertifiedDiplomat  d AdoptionServiceProvider ( x www.lifefocuscenter.com <  # ?ir##XX#BACKGROUNDINFORMATION <  ABOUTTHEPROSPECTIVEADOPTIVEPARENT(S) (x   +0  0` (#(#0 ` (#` (#0 (# (#0h(#(# h(#h(# PleasecompletethisformandreturnittoDr.ElaineKindlepriortotheAdvisement.According <  toFamilyCode,yourinformationandoriginalsignaturesneedtobeinyourASPsadoption ( casefile.Thankyou.  0  0` (#(# ` (#` (#  IdentifyingInformation:      ` Name(s):____________________________________________________________________ ` Address:____________________________________________________________________ 8 Ѐ0 ` 0 ` (#` (#Street0 (# (#0h(#(#0h(#h(#0(#(#City0p(#(#0p(#p(#0 (#(#Zip$t (# (# CountyofResidence:_______________________Homephone:_________________________ L (X(#(#(Name:______________________________  Workphone:_________________________ ! Cellphone:__________________________ p#  Fax#:______________________________ H% "    `     h Emergencycontact:___________________  (\#%    `    ___________________________________ )4%'  + ')  Pleaseincludeareacodesforallnumbers.  ) Name:______________________________ !+ Workphone:_________________________ p#- Cellphone:__________________________ H% / Fax#:_______________________________  'p"1 Emergencycontact:___________________ )4%4 ___________________________________ + '6 (X( APBackgroundInformation,cont.       (X(#(#(ADOPTIVE PARENT:   FullLegalName:__________________________ d Age:_______________DOB:___________ <  Religion:________________________________  d _SSN_:_________DriversLicense:____________  <  Race/Ethnicity:___________________________   No.ofPreviousMarriages:__________________   HighestEducation:________________________ t Profession:______________________________ L Employment:____________________________ $t GrossAnnualIncome:_____________________ L @@/@   ADOPTIVEPARENT:   FullLegalName:_____________________ ` Age:___________________DOB:_______ 8  Religion:____________________________  `  _SSN_:__________DriversLicense________  8 " Race/Ethnicity:_______________________  $ No.ofPreviousMarriages:_____________  & HighestEducation:___________________ p( Profession:_________________________ H* Employment:_______________________  p, GrossAnnualIncome:_______________ H. (X@@( XX .  Pleaseanswerthefollowingquestions:#   .B##XX ##0  0(#(#0p(#(#0p(#p(#0 (#(#. (# (#  Please listthename&phonenumberofyourattorney:________________________________ n 0 ____________________________________________________________________________ J"2  What isthenameofyourbirthparent:_____________________________________________ "$r4  When wereyoumatched?_______________________________________________________ %N!6  Do youhavecontactwiththebirthparent?Explain:___________________________________ '*#8 ____________________________________________________________________________ )%:   +&< ЇAPBackgroundInformation,cont.      What isthedateofyourmarriageordomesticpartnership?_____________________________ t  Do youhaveanychildren?Ifso,pleaseprovidetheirnamesandbirthdates.Arethesechildren P  adopted,fromthismarriage,orfromanothermarriageorrelationship? @  ____________________________________________________________________________  h _____________________________________________________________________________  @  _____________________________________________________________________________    Do eitherofyouhavechildrenfrompreviousmarriagesorrelationshipswho donotliveinthe   home ;doyouhavechildsupportobligationsforthesechildren;andhaveyoumetanychild | supportobligations?Ifyes,alsopleaseidentifywhosechildrentheyare,andtheirnamesand l ages: X ___________________________________________________________________________ 0 ___________________________________________________________________________ X  Have eitherofyouhadanychildrenremovedfromyourcareduetochildabuseorneglect?If  yes,pleaseexplainwhoandwhy:   ___________________________________________________________________________  ____________________________________________________________________________ l   What areyourchildcareplansforthechildyouareplanningtoadopt? 0#! ___________________________________________________________________________  $p" ___________________________________________________________________________ %H!$  Are thereotherchildrenand/oradultsresidinginyourhome?Ifyes,pleasewritethenamesand ' #& agesbelowandidentifytowhomtheyarerelated: ($' ____________________________________________________________________________ *%)    `  +&*  APBackgroundInformation,cont.      Do eitherofyouhaveanyhealthconditionsrestrictingyournormaldailyactivitiesorreducing t yournormallifeexpectancy?Ifyes,pleaseexplain: d _____________________________________________________________________________ <  _____________________________________________________________________________  d  Are youtakinganymedications?Forwhatpurpose?Pleaseincludeany_psychotropic_  <  medications. ,  _____________________________________________________________________________   _____________________________________________________________________________    Do eitherofyouhaveanyconvictionsforcrimesotherthanminortrafficviolations?Ifyes,that P personneedstoanswerthequestionbelow.Youwillneedtoincludeanyinformationregarding @ anyarrestsorconvictions,whetherornottheyweredismissedorexpungedfromyourrecord. ,| Thisinformationisreleasedto_SDSS_Ԁand_CDSS_Ԁwhosharesthisinformationwiththe h _birthparent_(s).Yourfailuretoreportanysuchconvictionsorarrestsmayjeopardizethis T adoption: @ ___________________________________________________________________________  ___________________________________________________________________________   Has yourhomestudybeencompleted? Yes/No  d  (TypicallyhomestudiesarecompletedafterplacementinIndependentAdoptions) T!   Do youanticipateanyfinancialdifficultyshouldaplacementhappenimmediately? Yes/No  $h"   Do youunderstandthefunctionoftheAdoptionServiceProvider? Yes/No &0"%    Have youreadtheFeeAgreementanddoyouunderstandandagreetothechargesandtime )$( lines? Yes/No  *%)    +&* Ї APBackgroundInformation,cont.      What otherinformationwouldyouliketohaveregardingthisadoptionprocess? t _____________________________________________________________________________ P  _____________________________________________________________________________ ( x  Is thereanyotherinformationaboutyourselvesyouwouldliketoinclude? (  _____________________________________________________________________________   _____________________________________________________________________________   ________________________________________________________________________ (  ProspectiveAdoptiveMothersSignature0  0(#(#ProspectiveAdoptiveFathersSignature(#(#  @*________________________________________________________________________ \   Date0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#DateH!(#(#  5/05