Cunningham Law Professional Corporation | Adoption (Relative) Questionnaire: Client Intake Form

Today’s date:

Repeat client:

Yes

Referred by:

PLEASE COMPLETE TO THE BEST OF YOUR ABILITY AND RETURN.

INFORMATION FOR ADOPTIVE PARENTS (order of information provided is of no significance):

Parent 1

Full Legal Name:

Date of Birth:

Gender?

Male

Female

Other

Resided in Ontario since:

Driver’s License No.:

Other ID (Specify Type & No.):

Current Address (#/Street):

City/Province/Postal Code:

Resided at Current Address since:

Home Telephone:

Other (cell):

Email:

Fax No.:

Occupation(s):

Parent 2 (if applicable)

Full Legal Name:

Date of Birth:

Gender?

Male

Female

Other

Resided in Ontario since:

Driver’s License No.:

Other ID (Specify Type & No.):

Current Address (#/Street):

City/Province/Postal Code:

Resided at Current Address since:

Home Telephone:

Other (cell):

Email:

Fax No.:

Occupation(s):

If the person applying to adopt is involved in a spousal relationship, has the spouse consented to the adoption:

if NOT, why not:

INFORMATION ABOUT BIRTH PARENTS:

What is the full legal name of the birth parents:

Address or contact information of the birth parents:

Do you have consent of both birth parents to adopt:

If NOT, why not:

Does birth parent(s) have a lawyer

and if YES please provide name and contact information for the lawyer(s):

INFORMATION FOR ADOPTIVE CHILD(REN): (order of information provided is of no significance):

Child 1

1. What is the full legal name of child

2. What is the child’s date of birth?

3. How old is the child?

What is the child’s gender?

Male

Female

Other

5. What is the child’s Birth Registration Number?

6. Where is the child’s place of birth? (municipality, province and country)

7. Does the child have siblings by the birth parents?

and if YES, please provide name, date of birth and address (if known)

8. Will the adopted child have a relationship with such siblings or the extended family?

and if NO, why not:

9. What will be the full legal name of child after adoption?

10. What is your Relationship to the client through bloodline or marriage (i.e. step parent, aunt, uncle, grandparent etc.):

11. Explain reasons for adoption (if space not sufficient, please include on separate page):

Child 2 (If APPLICABLE)

12. What is the full legal name of child

13. What is the child’s date of birth?

14. How old is the child?

15. What is the child’s gender?

Male

Female

Other

16. What is the child’s Birth Registration Number?

17. Where is the child’s place of birth? (municipality, province and country)

18. Does the child have siblings by the birth parents?

and if YES, please provide name, date of birth and address (if known)

19. Will the adopted child have a relationship with such siblings or the extended family ?

and if NO, why not:

20. What will be the full legal name of child after adoption?

21. What is your Relationship to the client through bloodline or marriage (i.e. step parent, aunt, uncle, grandparent etc.):

22. Explain reasons for adoption (if space not sufficient, please include on separate page):

23. If more than 1 child is to be adopted, are the children related?:

and if YES, what is the relationship (i.e. siblings, cousins etc.):

24. Are there any other children in the adoptive family?:

and if YES, (List: Name and Date of birth):

Name

dd/mm/yy

Name

dd/mm/yy

Name

dd/mm/yy

RELATIVE ADOPTION

DOCUMENTS TO BE PROVIDED BY THE CLIENT(S)

(originals where available)

1. Child(ren)’s birth certificate(s) or statement of live birth:

2. Proof of age of adoptive parent (i.e. birth certificate, driver’s license, passport)

3. Adoptive parents marriage certificate, if married

4. Proof of Death of a birth parent, if applicable

5. Any Court Orders (i.e. for custody, access, guardianship) or Written Agreements

6. Any additional information you believe to be relevant

Other:

10.