Adoption Agency Research Questionnaire

Agency Name: __________________________________Date Contacted: __________________ Name/Title of the Person Spoken to: _____________________________________________________ Phone: _________________________ Ext. _________ E-Mail: __________________________________ How long has the agency been in business? ______________________________________________ How many adoptions has this agency facilitated? ________________________________________ How long (or how many adoptions) has the agency been facilitating adoptions in thecountry of interest to you? _______________________________________________________________ What state does this agency operate out of? ______________________________________________

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Is this the same state in which the agency is licensed to perform adoptions and wherethe agency is incorporated (or where they are registered as a non-profit organization)?

YESNO

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If yes, what is their license number? _______________________________________________

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If no, record information about their license and business incorporation or non-profitstatus here: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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Who is the owner of the business? _________________________________________________

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Who is the Executive Director? _____________________________________________________

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Has the owner or Executive Director ever owned or operated an adoption agency inanother state?

YESNO

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If yes, in what state and what was the name of the agency and the reason the agencyis no longer in business? __________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

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Has the owner or Executive Director ever had their adoption agency license revokedor requested to be surrendered?

YESNO

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For domestic adoption

: What support services (legal advice, counseling) is offered tothe natural mother and natural father before, during, and after placing their child foradoption? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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For International Adoption: Does the agency have Hague Accreditation, and if so, what type?

YESNO

________Accredited ________Temporary Accreditation (1 yr.) ________Temporary Accreditation (2 yr.) ________Approved For Profit Service Provider

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Is the agency a member any professional organizations? ____________________________________________________________________________________ ____________________________________________________________________________________

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What support or educational opportunities are available for Adoptive Parentsusing this agency? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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Does the agency charge a different fee based on race, ethnicity, or gender?

YESNO

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Does the agency offer grants for adopting a child with special needs?

YESNO

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What post-placement support is available? ______________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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Have any adoptions facilitated through this agency been disrupted?

YESNO

How many? _________________

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Does the agency assist adoptive parents facing a disruption of a child adoptedthrough their agency?

YESNO

If yes, in what manner is the family assisted? ______________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________

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Is the agency fiscally sound? You can check many non-profit organizations’ financial records at www.guidestar.com. Request the agency’s financial recordsdirectly. Are they willing to disclose this information?

YESNO