ADOPTION FORMS FOR WEBSITE GENERAL FORMS Dear Adopting Parent Letter Child’s Medical - Full Report Disclosure Form Email Communication Consent Form Employment Verification Letter Fee Schedule Fire Arms Ownership Statement Guardianship Form for Maryland Residents Guardianship Form for Virginia Residents Immigration Authorization Form Interstate Acknowledgement Form Permission to Release the Home Study Form Short Medical Form – Adult Short Medical Form – Child Teacher Questionnaire Adult’s Medical – Full Report Authorization for Release of Information Release of Criminal History Record Form

Dear Adopting Parent: Adoption Options is a program of the Jewish Social Service Agency offering adoption services on a non-sectarian basis. JSSA's adoption program provides assistance with domestic, parental, private, designated and international adoption placements for residents of Maryland and Virginia. Our services include; adoption home studies, post-placement supervision, birthparent counseling and adoption counseling. People electing to participate in a private, parental or international adoption select a course, which maximizes their direct involvement and control over the adoption process. Whether you adopt privately or overseas, you will find that the home study is the first part of the process. The purpose of a home study is to help applicants evaluate their readiness to become adoptive parents and to educate themselves about issues that are unique to adoptive parenting. The enclosed materials are designed to help you take a more active part in preparing for your home study. The fee for a DOMESTIC OR NON-HAGUE COUNTRY HOME STUDY is $1700.00, plus a non-refundable application fee of $100.00, payable in at time of application. The fee for a HAGUE COUNTRY HOME STUDY is $1850.00, plus a $100.00 non-refundable application fee, payable at time of application. The fee for an EXPEDITED (RUSH) HOME STUDY is $1,900.00, plus a $100.00 non-refundable application fee, payable at time of application. Please note that the time period required for a home study is largely dependent on how quickly supporting documentation is received. Maryland has different requirements from Virginia. Maryland home studies generally take more time because additional documentation by other agencies is necessary. In Maryland a sanitary survey by the local housing department is required. Most recently, the sanitarians have been taking two months to do these. In addition, Maryland has a requirement for a fire safety inspection. You will therefore need to contact your local fire department to come to your home for an inspection. Maryland police record checks must be fingerprint supported and the record check is done through the FBI. If you choose to have your fingerprints taken at a local police department, you run the risk that the fingerprints will not meet FBI standards and will be returned to us. We strongly urge you to take the time to go directly to the CJIS office in Reisterstown, Maryland (410-764-4501). Normally the criminal record check takes about two months to come back to us. If your fingerprints are rejected, it still takes two months for us to receive the rejection. The FBI will not do a record check by name until fingerprints have been rejected twice so it is possible that the criminal record check could take six months.

Virginia residents: Please see the attached forms, which explains the State Police and Child Protective Service requirements for Virginia. Applicants are responsible for all charges made for criminal record checks, fire safety inspection, sanitary survey, as well as the costs of any corrective actions required to meet local standards. Applicants are responsible for the costs of required documentation for international adoptions. If you are pursuing an international adoption, you are responsible for applying to the Immigration and Naturalization Service for an orphan petition (INS form I600 or I600A, depending on whether you have identified a specific child). You may apply to INS after you have received your home study. Or, you may begin your INS work while your home study is in process. However, it can not be approved until the INS has your completed home study. You are responsible for having the home study translated. Generally, this can be done through your liaison agency. In Maryland, the INS petition also takes about two months. In a private adoption, services to birthparents and other related adoption services are billed at $100.00 an hour. Post-placement supervision for all adoptions is available for $350 per visit for one child and $475 for two children. The court report cost is $350 for one child and $475 for two children. All fees are subject to change. Jewish Social Service Agency is a licensed child placement agency in Maryland and Virginia. The adoption regulations for these jurisdictions are rigorous and no waivers are allowed for any of the requirements. Although the paperwork involved in an adoption may initially seem daunting, please remember that it is just a step in your goal towards being adoptive parents.

We wish you success in your journey towards parenthood. The Staff of Adoption Options

JEWISH SOCIAL SERVICE AGENCY – ADOPTION OPTIONS Beth Lutton, LCSW-C Beth Lutton, LCSW-C 6123 Montrose Road 3018 Javier Road Rockville, MD 20852 Fairfax, VA 22031 301-816-2697 FAX: 301-816-2628 703-204-9592 Fax 703-204-9590

CHILD’S MEDICAL – FULL REPORT

1. NAME:____________________________BIRTH DATE:_________________ 2. DATE EXAMINED:________________BY____________________________ 3. WEIGHT:____________ HEIGHT:______________ NORMAL WEIGHT:_____________ 4. GENERAL APPEARANCE:________________ POSTURE:_____________ 5. SKIN:_______________________ TEMPERATURE:___________________ 6. HEAD:_________ EYES:________ EARS:__________ TEETH:_________ 7. TONSILS:_________________ THYROID:___________________________ 8. CHEST:___________________ HEART:_____________________________ 9. LUNGS:___________________ ABDOMEN:_________________________ 10. GENITALS:________________ EXTREMITIES:______________________ 11. LYMPH NODES:_______________________________________________________________ 12. RECOMMENDATIONS:________________________________________________________ 13. Any special examinations?_______________________ Dates:_______________________ 14. Any hospitalizations?____________________________Dates:________________________ 15. Childhood Illnesses:___________________________________________________________ 16. The last PPD TEST was on _________________ and the results were ______________.

(If the doctor does not feel this test is necessary – say not needed an initial it.) 17. Is child free of communicable diseases and in good general health?_____________ 18. Have you shared the above findings with this child’s parents?__________________ _______________________________ ____________________________________ Date of exam Physician’s signature Physician’s name printed:_______________________________________

JEWISH SOCIAL SERVICE AGENCY

ADOPTION OPTIONS

DISCLOSURE FORM I, , hereby declare or affirm under Penalty of Perjury, that I have not been convicted of, nor am I the subject of pending charges or have ever been the subject of charges for the commission of attempt to commit/or assault with intent to commit: Murder; Child Abuse; Rape; Child Pornography; Child Abduction; Kidnapping of a Child; manufacturing, distributing, or dispensing a controlled angerous substance; possession with intent to manufacture, distribute or dispense a controlled dangerous substance; or hiring, soliciting, engaging, or using a minor for the purpose of manufacturing, distributing, or delivering a controlled dangerous substance; or a Sexual Offense, defined by the laws of any state or any jurisdiction. I, , further declare that I have never had a problem with substance abuse of any type including prescription drugs, narcotics, amphetamines, "street drugs," or alcohol. I have never been in a drug rehabilitation program. I, , further declare that I have not been convicted of child abuse or domestic violence; nor have I been involved in any form of domestic violence or child abuse under any circumstances. I, , further declare that I have never been rejected for placement by an adoption agency or other authority and hereby state my understanding that the adoption agency and the Immigration and Naturalization Service will verify these statements through criminal background checks, etc. I, , hereby state my understanding that the adoption agency and/or the Immigration and Naturalization Service may reject my application for adoption if I have been untruthful about the foregoing issues. Signature:________________________ Date:_________________ Name printed:_______________________________ Disclosure form

CONSENT TO COMMUNICATE VIA E-MAIL The Jewish Social Service Agency ("Agency") is pleased to provide you with services. We will do our best to serve you well. As a recipient of Agency services, if you elect to communicate with your case worker via e-mail, and request that your home study draft be forwarded to your placing agency via email, the Agency will take reasonable measures to secure the transmission and storage of e-mail communications between you, your placing agency, and any Agency staff person. However, once the Agency transmits an e-mail to you or your representative, the Agency is not responsible for ensuring that (i) the e-mail is not received or viewed by person(s) other than the intended recipient(s), (ii) the e-mail reaches the intended recipient(s), or (iii) the intended recipient(s) maintain the security of the e-mail or the confidentiality of the information contained in the email. The Agency disclaims all liability arising from or related to (i), (ii) or (iii).

Further, if you elect to communicate with your case worker via e-mail, the Agency cannot and does not guarantee (i) when, or if, your case worker receives your e-mail or (ii) when your case worker is able to review and respond to your e-mail. The Agency disclaims all liability arising from or related to (i) or (ii). ________________________________________________________________

PLEASE INITIAL YOUR ANSWER IN THE PARAGRAPH BELOW:

I understand and agree to abide by the Agency's statement of email communications. I understand and agree that using e-mail to communicate with my case worker (i) may result in the viewing or disclosure of personal information about me or my family members to unintended third parties. I understand these risks and limitations and, accordingly, I hereby do ___ (initial) do not ___ (initial) authorize the Agency to communicate with me, my placing agency, my legal representatives and any other individual involved in my case (except as expressly restricted by me).

_____________________________________ ______________ Signature of Client Date Name printed:_________________________________ ______________________________________________ Email address you wish the Agency to use.

EMPLOYMENT REFERENCE REQUIREMENTS

FOR HOME STUDIES:

______________________________

One of the requirements for a home study is an employment verification letter from the applicant’s employer. ♦ Please complete the enclosed Authorization to Release

Employment Information form and take it and the enclosed letter to the person at your place of work who can complete this request.

♦ Please be sure to include your name on the RE: line of the

letter. ♦ The completed employment verification letter should be sent

to:

Judith A. Miller Executive Assistant Adoption Options – JSSA 6123 Montrose Road Rockville, MD. 20852

A copy can be faxed to me at 301-816-2628, however, the original letter must be mailed to the above address, as the original must be maintained in your record. If you have any questions about this procedure, please call me at 301-816-2697. Thank you, Judy Miller Executive Assistant

AUTHORIZATION TO RELEASE

EMPLOYMENT INFORMATION

TO THE JEWISH SOCIAL SERVICE AGENCY

ADOPTION OPTIONS

To Whom It May Concern: I,__________________________ SS#_______________________, hereby give my authorization to: My employer, _______________________________________, (Company name) Individual’s Name:___________________________________, Business Address:______________________________________________,

Phone:__________________________________ to release to The Jewish Social Service Agency, T/A Adoption Options, information about my employment from my personnel records. Signature:___________________ DATE: ____________________

RE: To Whom It May Concern: The above-named individual has applied to the Jewish Social Service Agency, T/A Adoption Options for the purposes of completing an adoption home study. It is the responsibility of the applicant to obtain an employment verification letter from their employer. As many adoptions require a copy of the employment verification letter to be sent on to the placement source, we ask that the letter conform to the following standards: 1. Employment verification must be on company letterhead. 2. Letter must state the position the applicant holds, salary, length of

employment and prospects for continued employment. 3. Signature of company representative must be notarized and must also

reflect job title of the company representative signing the letter. (Notary is needed only if placing agency requires a notarized employment letter.)

4. This verification letter must be mailed to: Judy Miller, Executive

Assistant., JSSA/Adoption Options, 6123 Montrose Road, Rockville, MD 20852.

If you would like to share any additional information in your letter, please feel free to do so. If you have any questions, please call, Judy Miller, Executive Assistant, at (301) 816-2697. FAX : 301-816-2628 Thank you,

The Staff of Adoption Options

ADOPTION OPTIONS, A NONSECTARIAN PROGRAM OF THE JEWISH SOCIAL SERVICE AGENCY LICENSED IN MARYLAND AND VIRGINIA

FEE SCHEDULE Beth Lutton, LCSW-C, LISW Beth Lutton, LCSW-C, LISW 3018 Javier Road, 2nd floor 6123 Montrose Road Fairfax, Virginia 22032 Rockville, MD 20852 703-204-9592 301-816-2700 Judy Miller - 301-816-2697 Judy Miller - 301-816-2697 PHILOSOPHY: Adoption Options seeks to provide sensitive and knowledgeable assistance to all members of the adoption triad. The home study process is the first step in helping applicants to meet their goal of building their families through adoption. Our home studies offer an educational component while assisting applicants to explore their motivation and understanding of adoption related issues. Adoption Options provides counseling to birthparents seeking to design a well thought-out, permanent plan for themselves and their child. The program also offers ongoing counseling and support throughout the life cycle to birth parents, adoptees and adoptive parents to help facilitate a positive adjustment and adoptive experience. HOME STUDY FORMAT: Home studies are offered for international, domestic, private and parental placement adoption. The home study consists of joint and individual interviews; a home visit; and one in-person reference interview. There is a minimum of four contacts for couples and three with single applicants. TURN-AROUND-TIME: Home studies are completed in approximately 6 to 8 weeks, depending on client availability and receipt of supporting documents. EXPEDITED (RUSH) HOME STUDIES are completed in 3 to 4 weeks, depending on client availability and receipt of supporting documents. ADOPTION SERVICES OFFERED: 1) Pre- home study counseling sessions for individuals interested in learning

more about the adoption process and the various adoption alternatives. 2) Home studies for domestic, international, private and parental placement

adoption. 3) Counseling to birth parents considering adoption. 4) Post-Placement Supervision. 5) Post-adoptive counseling to adoptive parents and adoptees. 6) Adoption searches for adult adoptees and birth parents. ADOPTION SERVICE FEES: $150.00 PRE-home study counseling session available to couples and

singles exploring the option of adoption. These sessions are designed to assist prospective adoptive parents by providing

adoption information that will help them sort through the various adoption alternatives. The session is approximately two hours in length.

HOME STUDIES: $1700.00 Home study fee for domestic and non-Hague-country adoptions

plus $100 non-refundable application fee

$1,950.00 Home study fee for “Hague Country” adoptions plus $100 non-refundable application fee $1900.00 EXPEDITED (RUSH) home study fee – plus $100 non-refundable fee. $ 500.00 Home study update fee. If the original home study was

completed by another agency, there will be an additional fee of $75 for reviewing the original home study.

TRAVEL TIME $50/hour TRAVEL: An additional fee will be charged to clients who live

beyond 25 miles of the office. The fee is $50/hr. pro-rated for travel time after worker has traveled the initial 25 miles and mileage beyond the initial 25 miles will be billed at the prevailing government rate. For applicants living outside the program’s normal geographic area where all interviews will take place in the client’s home, mileage and travel fees will be applied to each interview including post placement visits and updates.

POST-PLACEMENT SERVICES: (Cost covers home visit/interview and written report) $ 350.00 Per visit for one child $ 475.00 Per visit for two children

(The exact number of post-placement contacts will be dictated by the placing agency, state or country in which the child/children were born.)

FINALIZATION $ 350.00 Court Report preparation for finalize or re-finalization for one child $ 475.00 Court Report preparation for finalize or re-finalization for two children (Court Reports are required for finalize or re-finalization only in VA COUNSELING $ 130.00/hour Post Adoptive Counseling for families or individuals $ 100.00/hour PRE-PLACEMENT COUNSELING: (FOR birth parents & families in

private and parental placement adoptions) TRAINING $ 200.00 Training for non-JSSA VA Adoptive Parent in the state required Core

Competencies $ 100.00 For JSSA clients SEARCHES: $1000.00 Identifying information search $ 500.00 Non-identifying information search PREPARATION OF FORMS: $ 30.00 Minimum fee for foreign documentation preparation billed at

$60/hour. REFUND POLICY: If either the applicant or the social worker terminates a home

study before it is completed; the time spent in interviews or on behalf of the applicant will be

multiplied by $130/hr. That amount will be subtracted from the original home study fee

that was paid, and any balance, excluding the non-refundable application fee, will be refunded

to the applicant. If applicants are pursuing a Parental Placement (Virginia’s form of private adoption), an escrow account of $1,500 is required against which the cost of providing mandated counseling to the birth parents and the adoptive couple will be charged at $100 an hour. The court required Report of the Home Study, Report of Visitation and the cost of post-placement supervision will also be charged against this account. Fees could potentially exceed $1.500 depending on the complexities of the individual case. Itemized statements of service will be provided to the adopting parents and any unused monies will be returned after finalization. It is understood that should fees for any of these services increase,

either before or during the time these services are being provided, the applicant will be responsible for reimbursing Adoption Options/JSSA at the higher fee. If the applicant has prepaid for these services, it is understood that they will be responsible for paying the difference between what had been paid and the new fee.

Fee schedule 2014

POSSESSION/OWNERSHIP

OF FIREARMS _________________________________________

This signed statement is required

For all prospective adoptive parents involved

In the Adoption Home Study process

AND ANY ADULTS LIVING IN THE HOME PLEASE BE SURE TO CIRCLE YOUR ANSWERS BELOW:

♦ I / WE do / do not possess or own firearms of any kind.

♦ I / WE do / do not have firearms stored in

my home. ________________________________________ ______________________ Prospective Adoptive Parent DATE _________________________________________ Name printed ________________________________________ _______________________ Prospective Adoptive Parent DATE _________________________________________ Name printed

Adoption Options/JSSA Guardianship Statement for Maryland Residents

Adoptive Family: _________________________________________________________________

We have been made aware of Maryland’s state requirement to appoint a guardian for our adopted child in the event of a debilitating accident or illness or our untimely deaths. Our guardians will act on our behalf in the event of a debilitating accident, health problem or premature death that renders us unable to provide proper care for our child. Signatures: ______________________________ _________________________________

Adoptive Applicant Adoptive Applicant

After careful consideration, I/we have chosen: Name of Guardian(s)____________________________________________________ Relationship of named guardian(s) to applicants:_____________________________

Please provide the following information about the guardian(s) that you have selected. **Note: The guardian(s) do NOT have to be part of a married couple** Address and Phone Number of Guardian(s):__________________________________ ______________________________________________________________________________ Information on Guardian(s) Guardian #1 Guardian #2 Name: ____________ ________________ Age: ____________ ________________ Profession: ____________ ________________ Marital Status: ____________ ________________ Health: ____________ ________________ Annual Income: ____________ ________________ # & age of children in guardian(s) home: ___________________________________ This portion of the form must be signed by the guardian(s): We agree to act as guardians for the adopted child/children of the above-named family. We concur with the accuracy of the information about us present above and we fully accept the responsibility of overseeing the welfare of their adopted child/children in the event that they are no longer able to do so. Signatures: _______________________________ ______________________________ (Guardian #1) (Guardian #2) Date: _____________________________________

GUARDIAN FORM FOR VIRGINIA RESIDENTS APPLICANTS:____________________________________________ The home study process requires that you name a legal guardian for your adopted child or children. Please complete this form and send in with the packet forms or give to the social worker during one of the interviews. NAME OF GUARDIAN(s)________________________________________________________________ ______________________________________________________________________________ ADDRESS AND PHONE NUMBER OF GUARDIAN(s): RELATIONSHIP OF NAMED GUARDIAN(s) TO YOU: AGES OF GUARDIAN(s)_______________________________________________ IS/ARE THE GUARDIAN(s) MARRIED?_______________SINGLE?____________ DO THEY HAVE CHILDREN?______________________ AGES____________________ ANNUAL INCOME OF GUARDIAN(s)__________________________________________ HAVE YOU DISCUSSED THIS ISSUE WITH THEM AND HAVE THEY ACCEPTED THIS RESPONSIBILITY? WHAT MOTIVATED YOU TO SELECT THEM AS GUARDIANS?

AUTHORIZATION TO OBTAIN OR RELEASE INFORMATION TO

Beth Lutton, LCSW-C, the Executive Director of Adoption Services Or our caseworker

ADOPTION OPTIONS IS A PROGRAM OF THE JEWISH SOCIAL SERVICE AGENCY

RELEASE FORM FOR COUPLES

RESIDING IN MARYLAND AND VIRGINIA

I/We,_________________________________________give

Maryelizabeth Lutton, LCSW-C, the Executive

Director of Adoption Services, at the Jewish

Social Service Agency/Adoption Options, or any

JSSA/AO staff member, authorization to release

or obtain information from the National Benefits

Center (Immigration), regarding our pending or

approved adoption case. And also,

I/We,_______________________________ give the National Benefits Center

(Immigration), authorization to release any information to Maryelizabeth

Lutton, LCSW-C, Executive Director of Adoptions at JSSA, T/A Adoption

Options or a JSSA/AO staff member regarding our pending or approved

adoption case.

_______________________ _______________________ Signature Signature DATE:_________________________ _________________________________________________ Names printed

JEWISH SOCIAL SERVICE AGENCY

ADOPTION OPTIONS

INTERSTATE COMPACT ACKNOWLEDGEMENT I/We have been informed that there are laws concerning the transportation of children from one state to another. Before considering an Interstate Placement, we will seek information on the Interstate Compact and conform to these laws for the protection of the child. These procedures apply whether arrangements are made between agencies or the placement is a parental (i.e. private) placement. The Compact Office of both states must give approval for the placement, and considerable delay may result if contact is not made until the last minute. In an agency placement, it is the responsibility of the placing agency to obtain Compact approval. In a parental placement, the birthparents should be assisted with the necessary paperwork, as they are the "sending agency". NAME PRINTED:______________________________________________ Signed: ____________________________________ Signed: ____________________________________ DATE: _____________________________________

JEWISH SOCIAL SERVICE AGENCY

ADOPTION OPTIONS APPLICANT'S PERMISSION TO RELEASE HOME STUDY

We give our permission to the Jewish Social Service Agency,

Adoption Options, to release our adoption home study and any

documents or references which pertain to our desire to adopt to

any appropriate or requesting agencies or persons.

Signature of Applicant________________________________ Please print name_____________________________________ Signature of Applicant________________________________ Please print name______________________________________ Date form signed__________________________________

ADOPTION OPTIONS JEWISH SOCIAL SERVICE AGENCY

6123 Montrose Road Rockville, MD 20852

ADULT SHORT MEDICAL FORM I certify that __________________ remains in good physical and

emotional health; is free of communicable diseases; and has a

normal life expectancy.

She was last seen by me for a physical examination on

.

Her last PPD test was on and the results were

. (If doctor does not feel patient needs PPD test he should write, “not

needed” and initial it.)

I find this patient to be both physically and emotionally

capable of assuming the responsibilities of adoptive/foster

parenthood.

Physician's Signature _____________________ Physician’s name printed Date:___________________

Please Print Patient’s Name: _____________________

ADOPTION OPTIONS JEWISH SOCIAL SERVICE AGENCY

6123 Montrose Road Rockville, MD 20852

ADULT SHORT MEDICAL FORM I certify that __________________ remains in good physical and

emotional health; is free of communicable diseases; and has a

normal life expectancy.

He was last seen by me for a physical examination on

.

His last PPD test was on and the results were

. (If the doctor does not feel the patient

needs a PPD test he should write, “not needed” and initial it.)

I find this patient to be both physically and emotionally

capable of assuming the responsibilities of adoptive/foster

parenthood.

Physician's Signature _____________________ Physician’s name printed _____________________ Date:___________________

Please Print Patient’s Name: _____________________

ADOPTION OPTIONS

JEWISH SOCIAL SERVICE AGENCY

6123 Montrose Road, Rockville, MD 20852

CHILD'S SHORT MEDICAL FORM

I certify that ______________________________ (DOB:_____________) remains

in good physical and emotional health; is free of communicable diseases.

He/She receives routine medical care and was last seen by me for a

checkup on __________________.

His/Her last PPD test was on _______________________ and the results

were ______________________________________. (if the doctor does not

feel this PPD test is necessary, he should write, not needed and

initial it.)

Physician's Name Printed: ______________________________________

Physician's signature:_____________________________________

Date form signed: _____________________________________________

CHILDS NAME PRINTED:_________________________________________

TO: PROSPECTIVE ADOPTIVE PARENTS: Residents of MARYLAND AND VIRGINIA

PARENT’S NAME:_________________________________ PLEASE FURNISH THE TEACHER’S NAME, THE SCHOOL, SCHOOL ADDRESS, AND PHONE NUMBER OF THE SCHOOL FOR EACH CHILD’S TEACHER, GUIDANCE COUNSELOR OR PRINCIPAL (ONLY ONE NEEDED FOR EACH CHILD), SOMEONE WHO YOUR CASEWORKER CAN CONTACT AS A REFERENCE. ALSO, PLEASE COMPLETE THE ENCLOSED AUTHORIZATION FORM, GIVING YOUR AUTHORIZATION TO YOUR CASEWORKER SO THAT SHE MAY SPEAK TO AND SEND A QUESTIONNAIRE TO THE TEACHER. Child’s name________________________ DOB:______________ THIS IS VERY IMPORTANT – PLEASE GET THIS INFORMATION TO ME AS SOON AS YOU CAN. TO SAVE TIME, ENCLOSED IS THE QUESTIONNAIRE

THAT WOULD BE MAILED TO THE TEACHER TO COMPLETE AND RETURN. PLEASE USE THE APPROPRIATE QUESTIONNAIRE (BOY OR GIRL) AND GIVE IT TO THE TEACHER WITH INFORMATION TO FAX AND/OR MAIL TO JUDY MILLER, EXECUTIVE ASSISTANT – ADDRESS BELOW.

THANK YOU, Judy Miller, Executive Assistant Jewish Social Service Agency/Adoption Options 6123 Montrose Road, Rockville, MD 20852 301-816-2697, Fax 301-816-2628

Jewish Social Service Agency Adoption Options

6123 Montrose Road, Rockville, MD 20852

AUTHORIZATION FORM FOR

TEACHER INQUIRY

RE:____________________________ Child’s name and date of birth I, _________________________, parent of _______________________, hereby give

permission to my adoption caseworker to speak to my child’s teacher, Ms./Mr.

_______________________, at the ______________________________ School. This is in

regards to my desire to pursue an adoption home study to expand my family by

adopting a child/children. (This is a home study requirement in the State of

Maryland.)

I give my permission to my caseworker to send a written questionnaire to the

teacher and also to contact the teacher by phone, if necessary.

____________________________________

Signature of Parent:______________________

DATE FORM SIGNED:______________________

School address:________________________________________________

School phone:__________________________________________________

TEACHER OR DAYCARE PROVIDER QUESTIONNAIRE

Child’s name and birth date: ____________________________________

REGARDING THE FAMILY’S PLANS TO ADOPT

1. Please describe her behavior in the classroom, at lunch, and on the playground. 2. Are there any particular problems you feel she is experiencing at school? 3. How does she get along with her classmates? 4. Have you had an opportunity to observe her interactions with her parents and

how would you describe their relationship. 5. Are her parents responsive to school input? SIGNED:_____________________________________ DATE: __________________ PLEASE PRINT NAME: ______________________________ PHONE NUMBER AND BEST TIME TO CALL:_____________________________

PERMISSION TO RELEASE PERSONAL REFERENCE

I hereby give my permission to have a copy of my reference letter, with regards to this adoption request, released to any relevant sources to facilitate the adoption process. I give this written permission in an effort to save time for the prospective adoptive applicants during this home study process. _______________________________________ _______________________________ Name Date Please return form to: Judy Miller, Executive Assistant Jewish Social Service Agency 6123 Montrose Road Rockville, Maryland 20852 Phone: 301-816-2697 and FAX: 301-816-2628

QUESTIONNAIRE FOR TEACHER OR DAYCARE PROVIDER

Child’s name and birth date: ______________________________________

REGARDINGTHE FAMILY’S PLAN TO ADOPT

1. Please describe his behavior in the classroom, at lunch, and on the playground. 2. Are there any particular problems you feel he is experiencing at school? 3. How does he get along with his classmates? 4. Have you had an opportunity to observe his interactions with his parents and how

would you describe their relationship. 5. Are his parents responsive to school input? SIGNED:_____________________________________ DATE: ____________________ PLEASE PRINT NAME: ______________________________________ PHONE NUMBER AND BEST TIME TO CALL:_____________________________

PERMISSION TO RELEASE PERSONAL REFERENCE

I hereby give my permission to have a copy of my reference letter, with regards to this adoption request, released to any relevant sources to facilitate the adoption process. I give this written permission in an effort to save time for the prospective adoptive applicants during this home study process. _______________________________________ _______________________________ Name: Date Please return form to: Judy Miller, Executive Assistant Adoption Options - Jewish Social Service Agency 6123 Montrose Road Rockville, Maryland 20852 Phone: 301-816-2697 FAX: 301-816-2628

JEWISH SOCIAL SERVICE AGENCY Beth Lutton, LCSW-C Beth Lutton, LCSW-C 6123 Montrose Road 3018 Javier Road Rockville, Maryland Fairfax, Virginia 22031 301-816-2700 FAX: 301-816-2628 703-204-9592 FAX 703-204-9590 MEDICAL REPORT FOR ADOPTIVE APPLICANTS (Please type or print) Name: Birth Date: _________________________ (please print name) MEDICAL HISTORY: (Please indicate dates attached to notations below:) Illnesses: Alcoholism Epilepsy_________________ Allergies Heart Disease____________ Arthritis Hypertension ___________ Asthma Kidney Disorders _______ Cancer Migraine _______________ Colitis Pelvic Disorder _________ Deafness Tuberculosis ____________ Diabetes Ulcers __________________ Disease of circulatory system STD's ___________________ Disease of nervous system HIV*** ______________ Disease of endocrine system Hepatitis_______________ Emotional Disturbance (all types) *** A HIV BLOOD TEST MUST BE DONE AND RESULTS FORWARDED TO JSSA. *** Other __________________________________________________________________ _________________________________________________________________________ Childhood Diseases: ___________________________________________________ _________________________________________________________________________ Operations: (please give dates) ________________________________________ _________________________________________________________________________ Accidents: (please give dates) _________________________________________ Psychiatric History (please give dates)__________________________________

PHYSICAL EXAMINATION: Weight Height Normal Weight General Appearance_______ Posture Skin Head Eyes Nose___________ Ears Teeth Tonsils Thyroid ______ Chest ___________ X-Ray Date (adults only) Result ____________________________ Heart Lungs Sounds Abdomen _______________ Tenderness Hernia Tumors Genitals ________________ Breasts Pap Smears - Test Date and Results ____________________ Rectal Extremities Lymph Nodes Temperature ___________ Blood Serology including HIV Date Results ____________ Document freedom from tuberculosis (include tests and results) ______________________________________________________________________________ Special Examinations and Dates ___________________________________________ _____________________________________________________________________________ Based on your overall knowledge, do you conclude that (s)he is physically and emotionally able to assume the responsibilities of adoption? _________ _____________________________________________________________________________ Does this individual have a normal life expectancy? _______________________ Have you discussed your findings and/or recommendations with this patient? ____________________________________________________________________ PRINT PATIENT'S NAME HERE: ___________________________________ Date Patient Examined ______________________________________ Physician Signature _______________________________________________ Doctor's Name (please print) ________________________________________ Address ______________________________________________________________ ______________________________________________________________ Phone ____________________________________ Date this medical form completed________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

___________________________________________________ DOB:_________________________ Printed Name of client

I authorize Adoption Options/JSSA, 6123 Montrose Road, Rockville, MD 20852 and 3018 Javier Road, Fairfax, VA 22031, Attn: Beth Lutton, LCSW-C; Executive Director of Adoption Services, 703-204-9592 and/or my Caseworker and/or the Executive Assistant, Judy Miller, 301-816-2697. Fax 301-816-2628 to obtain from [ ] and/or release/disclose to [ ]: Adoption Agencies, attorneys, Interstate

Compact Officials, Courts, Immigration, placing agencies, Licensing Authorities, medical

doctors & therapists.

Home studies and supporting documents including the following:

[ ] Counseling/psychotherapy/psychiatric report______________________________________ Please provide the name, address and phone of doctor

[ ] Medical information:____________________________________________ Please provide the name, address and phone of doctor [ ] Career and employment information [ ] Other non-health-related information,

Specify all State, County and Federal Clearances; reference letters, marriage and divorce certificates.

The purpose of this disclosure: The applicant is in the Adoption Home Study process with this agency. This RELEASE FORM also pertains to the AUTHORIZATION TO RELEASE copies of any and all supporting documents such as State Police and FBI clearances; Child Abuse Clearances; medical reports; and written references and any/all of the above mentioned documents. JSSA employees have a duty to maintain the confidentiality of any information disclosed to them pursuant to this authorization. The client or other authorized person may inspect the client’s records. However, this consent is subject to revocation by the client or other authorized person at any time, except to the extent that action has been taken in reliance upon it. _____________________________________ ______________________________ Signature of Client Date _____________________________________________ Name printed

RELEASE OF CRIMINAL HISTORY RECORD NEW LAW IN MARYLAND AND VIRGINIA

There is a "NEW LAW" that says that the Agency cannot release the police and FBI clearances to anyone except the individual. The only way the police and FBI clearances can be released to someone else, is that the individual must be the one to give them to the requestor. (Placing agency, attorney, judge, etc.) I can email the form to you, but we cannot accept a scan or fax back from you. You must sign, date and get the form notarized. Then you must either, hand deliver it to Beth Lutton or mail it to her. She cannot accept anything except a signed, notarized original.

Mail the signed, notarized form to Beth Lutton, LCSW-C at: Adoption Options/JSSA Beth Lutton, LCSW-C 3018 Javier Road, 2nd floor Fairfax, VA 22031 When Beth receives the form from you, she will mail it or have you pick up copies of the police and FBI clearances and you are then responsible to send copies to anyone who requests them. She can only give the clearances to the individual they are for, not to anyone else. So no one else can come and pick them up for you. However, Beth can mail the clearances directly to the individual in separate envelopes. I have attached the form for each of you. Please take care of this ASAP and get it back to Beth Lutton, LCSW-C. She will then give you copies of your police and FBI clearances. And, then you can give copies to anyone who requests them. This new law is self-explanatory; however, if you have any questions, please let me or Beth know. This new law makes things somewhat complicated, for our applicants and for the Agency, however, we must follow the LAW. Judy Miller Executive Assistant Phone: 301-816-2697 Beth Lutton’s phone 703-204-9592 Forms for packets: Release of criminal history record directions

Prohibition Regarding the Release of Criminal History Record Information Provided by the FBI and State Police Clearances

Pursuant to 28 C.F.R. Chapter 1, Section 20.1-20.38, criminal history record information obtained for the purpose of completing an adoption home study and pursuing placement is prohibited from being disseminated to attorneys, agencies or any third party by the home study agency. The only exception to this prohibition on dissemination of FBI and State Clearances is release to the applicants themselves as the applicant is a member of an exempt group. I, the undersigned, request that the Jewish Social Services Agency, a.k.a., JSSA T/A Adoption Options (hereafter “JSSA”) release a photocopy of my FBI and State Clearances to me. I have been informed that copies of these clearances will be required by attorneys, courts, adoption agencies, and the Interstate Compact on Placement of Children Office (“ICPC”) in order to facilitate an adoption.

I understand that it is my sole responsibility to provide copies of my clearances to adoption professionals assisting me with my adoption plan and that JSSA is prohibited from doing this on my behalf. Specifically, I understand that under no circumstances will JSSA fax, mail, delivery or otherwise provide copies of my clearances to any person other than myself. I understand I may not obtain copies of my clearances for my spouse, partner or any other person but that they must obtain those on their own behalf. I understand that without copies of my clearances a court, ICPC office, attorney or other adoption agency may refuse to place a child for adoption into my custody. I, the undersigned, agree and do hereby release from liability and agree to indemnify and hold harmless JSSA, and any of its employees or agents representing or related to JSSA including the Board of Directors for any and all liability occasioned by, or in connection with the release of the FBI and State Clearances to me. I understand that JSSA, its agents, employees and Board of Directors are not responsible for the actions taken by a person to whom or entity to which I release copies of my clearances. Signature: _________________________ DATE:____________________ Name Printed:_____________________________ STATE OF __________ COUNTY OF _____________ I HEREBY CERTIFY that on this _____ day of _______________, ______, before me, the undersigned officer, personally appeared __________________________, known to me or satisfactorily proven to be the person described in the foregoing document, and acknowledged that he/she executed the same in the capacity therein stated and for the purposes therein contained. IN WITNESS THEREOF, I hereunto set my hand and official Seal. ____________________________________ Notary Public My Commission Expires: __________

Prohibition Regarding the Release of Criminal History Record Information Provided by the FBI and State Police Clearances

Pursuant to 28 C.F.R. Chapter 1, Section 20.1-20.38, criminal history record information obtained for the purpose of completing an adoption home study and pursuing placement is prohibited from being disseminated to attorneys, agencies or any third party by the home study agency. The only exception to this prohibition on dissemination of FBI and State Clearances is release to the applicants themselves as the applicant is a member of an exempt group. I, the undersigned, request that the Jewish Social Services Agency, a.k.a., JSSA T/A Adoption Options (hereafter “JSSA”) release a photocopy of my FBI and State Clearances to me. I have been informed that copies of these clearances will be required by attorneys, courts, adoption agencies, and the Interstate Compact on Placement of Children Office (“ICPC”) in order to facilitate an adoption.

I understand that it is my sole responsibility to provide copies of my clearances to adoption professionals assisting me with my adoption plan and that JSSA is prohibited from doing this on my behalf. Specifically, I understand that under no circumstances will JSSA fax, mail, delivery or otherwise provide copies of my clearances to any person other than myself. I understand I may not obtain copies of my clearances for my spouse, partner or any other person but that they must obtain those on their own behalf. I understand that without copies of my clearances a court, ICPC office, attorney or other adoption agency may refuse to place a child for adoption into my custody. I, the undersigned, agree and do hereby release from liability and agree to indemnify and hold harmless JSSA, and any of its employees or agents representing or related to JSSA including the Board of Directors for any and all liability occasioned by, or in connection with the release of the FBI and State Clearances to me. I understand that JSSA, its agents, employees and Board of Directors are not responsible for the actions taken by a person to whom or entity to which I release copies of my clearances. Signature: _________________________ DATE:____________________ Name Printed:_____________________________ STATE OF __________ COUNTY OF _____________ I HEREBY CERTIFY that on this _____ day of _______________, ______, before me, the undersigned officer, personally appeared __________________________, known to me or satisfactorily proven to be the person described in the foregoing document, and acknowledged that he/she executed the same in the capacity therein stated and for the purposes therein contained. IN WITNESS THEREOF, I hereunto set my hand and official Seal. ____________________________________ Notary Public My Commission Expires: __________