Single Assessment Form Please fill out the entire form below so we can provide you with the most accurate feedback. Name* First Last Age*Address* Street Address City State / Province / Region ZIP / Postal Code Email* Enter Email Confirm Email Number of previous marriages, if any.*Employment Status*Full TimePart TimeNot EmployedAre You a US citizen?*YesNoBIRTH CHILDREN SECTIONNumber of birth children in your family*Age and gender of each birth child in your family*PREVIOUS ADOPTION SECTIONHave you previously adopted?*YesNoAge and gender of each adopted child in your family*What adoption organization did you adopt with?*OTHER IMPORTANT INFORMATION SECTIONDo you currently have a home study?*YesNoThere are many reasons that people wish to adopt. Please share your reasons for considering adoption.*Is infertility an issue?*YesNoWhat type of adoption are you considering?*InternationalDomesticEitherHow many children are you considering adopting at this time?*Do you have a gender preference for this adoption?*MaleFemaleEitherDo you have an age preference for this adoption?*YesNoIf "Yes," what age categories are you interested in?*Do you have a nationality preference for this adoption?*YesNoIf "Yes," what countries have you been considering?*Knowing that the adoption process can easily take 1 year or more, how soon would you be ready to start the adoption process?*Would a child of a different race, ethnic background or culture be accepted in your social and family structure?*YesNoSome concernsIf you answered "No" or "Some Concerns," please specify your family's desired ethnicity when pursuing adoption.*Would you consider adopting a child with a mental disability?*YesNoWould you consider adopting a child with a physical disability?*YesNoWhat is your health status?*Have you ever taken or are you currently taking medication for depression or anxiety?*Never TakenHave Taken in the PastCurrently TakingIf you have taken medication for depression or anxiety in the past, how long has it been since you have taken this medication?*If you answered "Have Taken in the Past" or "Taking Currently," please explain the situation that resulted in the need for medication.*Have you been charged with or convicted of a felony or misdemeanor other than a minor traffic violation?*YesNoIf you answered "Yes," please explain and include how long ago the incident(s) occurred.*Have you ever abused alcohol or drugs or have a history of domestic abuse (including sexual abuse), even if you were not arrested or convicted?*YesNoIf "Yes," please explain and include how long ago the incident(s) occurred. Any information provided to Loving Shepherd Ministries will be kept strictly confidential.*What is your religion, if any?*If Christian, what is the name of your home congregation?*Will the cost of the adoption process place a financial burden on your family?*YesNoWhat is your total income from all sources (not including welfare subsidy, relief fund, pension, unemployment insurance or other form of government subsidy)?*The adoption process requires full disclosure of physical and mental health, financial history, and federal, state, and local background checks. Are you comfortable with these disclosures?*YesNoAdditional comments or questions?How did you hear about our services (family/friend referral, church, web search, LSM newsletter, LSM presentation, conference, etc.)?*Before pressing "Submit," please make sure that you have thoroughly completed the form. If you have left required fields blank, the form will not submit. Once you have successfully submitted the form, you will be taken to a confirmation page. Thank you!