Spence-Chapin
Adoption Service and Caring Since 1908

ASAP Pre-Application | Spence-Chapin Adoption Services
http://www.spence-chapin.org/z7_asap_preapplication_form.php

ASAP Pre-Application

If you are interested in adopting a child with special needs from our Domestic Adoption program, please fill out the form below. Thank you.

Fields marked with an * are required.

Personal Information


(Hold ctrl to select multiple race options from the lists below)
Parent 1
First Name *
Last Name *
Occupation *
Date of Birth * / /
Home Phone *
Mobile Phone
Work Phone
E-Mail Address *
Race
Gender *
Parent 2
First Name *
Last Name *
Occupation *
Date of Birth * / /
Mobile Phone
Work Phone
E-Mail Address *
Race
Gender *
Street Address *
City *
State *
Zip Code *
Marital Status *
Date of Marriage* / /

Children at Home

(Hold ctrl to select multiple race options from the lists below)
Child 1
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Child 2
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Child 3
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Child 4
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Child 5
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Child 6
First Name *
Last Name *
Date of Birth: * / /
Gender *
Race:
Child Origin *
Please use the "more about your family" section to tell us about any other children in your home

What characteristics in a child would best fit your family

(Hold ctl to select multiple race options from the lists below)
Gender
Race
Age Range
Medical Issues
Moderate non-correctable medical problems, such as some congenital anomalies and some syndromes.
Severe medical problems, such as: medically fragile, more severe cerebral palsy, shortened life span and multiple handicaps.
Extreme prematurity (26 weeks and under). Birth weight under 2 lbs. 8 oz.(Significantly increased risk for physical and neurological issues.)
Likely moderate cognitive disabilities- not Down syndrome
Down syndrome
Down syndrome with cardiac or other significant medical involvement
Brain anomolies- outcome uncertain
Anticipated severe to profound cognitive disabilities
Potential for serious and lifelong alcohol-related disabilities due to significant prenatal exposure to alcohol
Significant heavy use of drugs by birth mother- Child at risk for behavior, attention, learning and other challenges. (In these circumstances, alcohol use cannot be ruled out.)
Infant currently exhibiting atypical neurological development (e.g. hypertonicity, tremors, fisting) etiology is unknown. May significantly increase risk for neurological and behavorial issues as the child matures.
Child at risk for mental illness- one birth parent with psychiatric disorder
Child at risk for mental illness- both birth parents with psychiatric disorder
Other issues (Please note in comments section)
 
Legal Risk Placement

Home Study Agency
Name of Agency
Current Case Worker
Telephone Ext
 

Comments

If you need additional space for any answers, you can elaborate in the "More About Your Family" section below.
Other specific physical issues with which you are comfortable:
Other specific mental/cognitive issues with which you are comfortable:
Additional Comments:

Experience
What, if any, experience do you have caring for children with special needs:
 

More About Your Family
Is there anything else you wish to tell us about yourself and/or your family?
 

Where did you first hear about Spence-Chapin?*
If Other
 
410 East 92nd Street, New York, NY 10128 212.369.0300
Additional Adoption Offices in Hauppauge, Long Island and Summit, New Jersey

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