Adoption Service Provider (ASP) – Client Intake Form - Thank you for choosing me to provide Adoption Service Provider (ASP) services for your independent adoption. The information you provide below will help me understand the adoption plan, identify the individuals and professionals involved, and prepare to provide the necessary ASP services. Please answer the questions as completely as you can based on the information currently available to you. If you are unsure of an answer or do not yet have certain information, you may leave it blank and we can discuss it together.

Prospective Adoptive Parent Information

Please provide information for each prospective adoptive parent. If there are two prospective adoptive parents, click “Add Second Prospective Adoptive Parent” below to enter the second parent’s information.

Add Second Prospective Adoptive Parent (if applicable)

Street address

City

State

Zip

County of residence

Primary contact for ASP services

Prospective Adoptive Parent 1 Prospective Adoptive Parent 2

Primary Email Address for ASP Communications

Please enter the email address where you would like to receive confirmation and communications regarding ASP services.

Placing Parent Information

Placing Parent’s Full Legal Name

Date of birth (if known)

Phone number

Email address

Current City and State

Has the placing parent already spoken directly with you?

Yes No

Pregnancy / Child Information

Has the child been born?

Yes No

Estimated Due Date

Child’s Date of Birth (if already born)

Child’s Full Legal Name (if already born)

Adoption Professionals & Case Information

Are you currently working with an adoption attorney?

Yes No

Adoptive Parent Attorney Name

Law Firm address

Attorney Phone Number

Attorney Email Address

Referral Information

Who referred you to me for Adoption Service Provider services?

Is there anything else you would like me to know regarding coordination of ASP services?

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