Readiness Survey - USA Newborn Program

Applicant *

First Name Last Name

Co-Applicant *

First Name Last Name

Relationship Status *

Email *

example@example.com

Phone Number

Area Code Phone Number

Country of Origin *

If you responded "other", what is your Country of Origin?

How did you hear about Premier? *

1. Do you have a completed home study and provisional approval from your Central Authority? *

2. Do you have a Family Profile Book Completed? *

3. Are you gender specific? *

4. Are you specific about the race of your child? *

5. How open are you to prenatal alcohol exposure? Please mark all that apply. *

1st Trimester 2nd Trimester 3rd Trimester None

6. How open are you to prenatal drug exposure? Please mark all that apply *

1st Trimester 2nd Trimester 3rd Trimester None

7. Are you open to adopting a child whose parent(s) have a history of mental illness? *

8. Birth mother living expenses are common. Are you open to paying for her expenses if necessary? *

9. If yes, please specify the maximum amount that you are open to? *

Please provide any additional information that will help us get to know your family and your child preferences better.

10. After placement, are you open to communicating with the birth parent(s)? Mark all that apply: *

Letters/pictures through Agency Social Media Skype/Webcam Calls Email Visits I want a closed adoption Not sure