Personal Reference Questionnaire
Please fill out and submit this questionnaire form based upon your knowledge of the prospective adoptive parents.  It is critical that you answer all questions honestly and to the best of your ability as this information will be used to determine the appropriateness of placing a child permanently in this family's home.  If you have any questions or concerns, please contact Mary Duff, LMSW via email Thank you so much for your time and help! 
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Email *
First and Last Names of Prospective Adoptive Parents
Name of the child(ren) the parent(s) are seeking to adopt.  *
Your Full Legal Name *
Your Cell Phone Number  *
Your Physical Home Address to include City, State, Zip Code *
What do you do for a living? (Career, Student, Parent, etc) *
Your Relationship to the Prospective Adoptive Parent(s) *
How long have you known both or either prospective adoptive parent(s) *
How often and under what circumstances have you been in the parent(s) home? (i.e, family get together, etc).  *
Describe the family relationship in the home.  For instance, how do the members of the family relate to each other such spouse to spouse, parent to child, child to parent, sibling interactions.  *
Describe how the family relates to and/or is involved in the community.  Such as their involvement in community clubs, organizations, school, church, youth programs, volunteering, etc.  *
Are you aware of the prospective adoptive parent(s) having experience caring for a child or children? If so, please describe your observations of how they cared for and/or interacted with the child(ren).  In what capacity were they caring for the child(ren) (i.e., parent, babysitter, youth director, neighbor, etc,) What do you feel are the parent(s)' strengths and weaknesses based upon your observations? Please explain.  *
Please describe the ways in which the parent(s) discipline their child(ren).  Do you feel they discipline safely and appropriately? Please describe.  *
Please describe your overall impressions of the parent(s)' mental and physical health.  Are there any concerns regarding their ability to properly and safely care for a child or children? If so, please explain.   *
Are you aware of the parent(s) having a history of substance abuse disorders such as drug addiction or alcoholism? If so, please explain.  *
Are you aware of the parent(s) having a history of violence or abuse against children? Any DCS involvement or removal of children by the state? If so, please explain.  *
Please explain why you feel the parent(s) are a safe and proper placement for a child or children or why you feel they are not safe.   *
Please share any additional information about the parent(s) that you feel might be helpful in our assessment of the family.  *
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