Name: Pre-Application
Price: 150.00 USD
Availability: InStock

Please select your marriage status.*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Can we leave a voicemail?

Email*

Services Requested*

*Home Study Services are available to residents of North Carolina, South Carolina, and Virginia.

Please list placing agency, home study agency and/or attorney contact information (if applicable).*

Homestudy and Placement Information

How long have you lived in your current state of residence?*

Marriage Date*

MM

DD

YYYY

Applicant 1

Name*

First Middle Last

Nickname

Required if you prefer to go by a name other than your legal first name

Maiden Name

Required if applicable

Work Phone

Work Email

Cell Phone

Last 4 Digits of SSN*

Date of Birth*

MM

DD

YYYY

Place of Birth (City, State)*

Ethnicity (optional)

Height (Required for China and South Korea Adoptions)

Weight (Required for China and South Korea Adoptions)

Employer*

Occupation*

Yearly Salary*

Other Financial Resources (optional)

Is this applicant a U.S. citizen?*

Yes
No

Has this applicant been in a prior marriage?*

Yes
No

Please enter prior marriage dates*

Has applicant ever been separated from current spouse?*

Yes
No
N/A

Name, gender, and birth date of any children

Has this applicant been treated for a medical condition?*

Yes
No

If yes, explain circumstances and dates.

Has applicant ever undergone counseling?*

Yes
No

If yes, explain circumstances and dates of treatment.

Has applicant ever been treated for emotional condition?*

Yes
No

If yes, explain circumstances and dates of treatment.

Has this applicant ever been arrested, have criminal records or convictions? Please include juvenile or expunged records.*

Yes
No

Please provide dates and circumstances

Has this applicant ever been accused of child abuse, neglect, and/or domestic violence?*

Yes
No

Please provide details.

Does this applicant have any history of substance abuse?*

Yes
No

Please provide details

Has applicant ever filed for bankruptcy?*

Yes
No

If yes, please provide dates and circumstances.

Applicant 2

Name*

First Middle Last

Nickname

Required if you prefer a name other than your legal first name

Maiden Name

Required if applicable

Work Phone

Work Email

Cell Phone

Last 4 Digits of SSN*

Date of Birth*

MM

DD

YYYY

Place of Birth (City, State)*

Ethnicity (optional)

Height (Required for China and South Korea)

Weight (Required for China and South Korea)

Employer*

Occupation*

Yearly Salary*

Other Financial Resources (optional)

Is this applicant a U.S. citizen?*

Yes
No

Has this applicant been in a prior marriage?*

Yes
No

Please enter prior marriage dates

Has applicant ever been separated from current spouse?*

Yes
No
N/A

Name, gender, and birth date of any children

Has this applicant been treated for a medical condition?*

Yes
No

Please provide details

Has this applicant ever undergone counseling?*

Yes
No

If yes, please describe dates and circumstances.

Has this applicant been treated for an emotional condition?*

Yes
No

If yes, please describe dates and circumstances.

Has this applicant ever been arrested, have criminal records or convictions? Please include juvenile or expunged records.*

Yes
No

Please provide dates and circumstances

Has this applicant ever been accused of child abuse, neglect, and/or domestic violence?*

Yes
No

Please provide details.

Does this applicant have any history of substance abuse?*

Yes
No

Please provide details

Has applicant ever filed for bankruptcy?*

Yes
No

If yes, provide dates and circumstances.

Placement Preferences

Country you are applying for?*

Gender you would like to adopt?*

Number of children*

Age Range

ex: 2-4 years

Have you ever been turned down by an adoption agency?*

Yes
No

How did you hear about Carolina Adoption Services?

Is this application for an already adopted child or child already in the home?*

Yes
No

Post-Adoption, Relative, or Step-Parent applicants.

Please provide birth name, adoptive name, date of birth, place of birth, date of adoption (if applicable) of children to be adopted/re-adopted. For Post-Adoption Only families, please also provide date of next post-adoption report.

I have read and accept the CAS Client Policies*

Yes
No

How did you hear about us?

Did you talk to someone on our staff before completing this application?

If 'Yes', please let us know who you talked to.

Total

$0.00

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