Stepparent Adoption Home Evaluation Questionnaire

Applicant Information

Full Name Date of Birth Relationship to Child Address

Household Members

List all household members and their relationship to the child

Marriage/Partnership

Date of Marriage/Partnership Duration of Relationship

Child Information

Child's Full Name Child's Date of Birth Current School/Grade

Background

Describe your motivation for stepparent adoption Relationship history with the child

Child's Birth Parent (Non-Custodial)

Full Name Relationship/Contact with Child

Home Environment

Describe your home environment (living arrangements, space, etc.)

Employment & Financial Information

Current Employment (Applicant) Household Income Any financial concerns?

Health & Background Checks

Any history of criminal or child welfare involvement? Applicant's physical and mental health status

Additional Comments

Any additional relevant information