QUESTIONNAIRE FOR RELATIVE/STEP-PARENT ADOPTION

A. ON THE CHILD

I. IDENTIFYING INFORMATION

Name (First, Middle and Last Name. For

Child Without Known Parents, indicate the
given first and last name and alias, if
applicable)

Sex

Date of Birth/Given Date of Birth

Age

Place of Birth/Place Found

Birth Status (Marital/Non-Marital/Child)

Health condition (healthy or with special

needs, specify)

Current Whereabouts (Name and Address

of Current Custodian/Known Parents)

III. BACKGROUND INFORMATION

Description of Child upon Placement

This section must include the following information which should be presented in a
brief/concise, accurate/factual manner:

● Age, personality, physical deformities (if any), birthmark/s (if any) and other
significant observations about the child upon admission

● Data on anthropometric measurements of the child

● Description of the child’s overall appearance to indicate whether the child was properly
cared for

● Type of clothing and hygiene (e.g. clean or unkempt). (Graphic details should not be
included)

● Developmental achievements of the child (e.g. fine/gross motor skills, speech and
language, etc.)
Medical History of the Child:

1. Circumstances of birth (e.g. type of delivery, place of birth, birth weight/length,

head/chest/abdomen circumference, result of newborn screening, age of gestation at
birth (weeks/months). If born in a hospital, include Ballard and APGAR score, hearing
test, eye test and immunizations given at the hospital. For accurate data, refer to the
nursery record/medical abstract of the child from the hospital

2. For a prematurely born child with positive G6PD test result, confirmatory test is
required to confirm G6PD.

3. For a child born with ear deformities, consult the pediatrician for recommendations on
further testing to determine other related deformities.

4. For a child born with cleft lip and/or cleft palate, consult pediatrician for determination
of treatment and timing of surgical correction, if necessary.

5. Information on whether the child was breastfed by the birth mother. If not, include
reason why. Information should be contextualized.

6. Immunizations received by the child (in tabular form).

7. If the child lived with the birth mother, stayed with relatives, guardians, or child
caring agency, indicate length of stay and medical history prior to admission.

8. For a child born from a mother with history of substance abuse or sexually transmitted
disease/s, include result of laboratory tests. If there are no tests done, facilitate
laboratory testing to determine possible transmission of infection to the child.
 9. Minor and major illnesses of the child including hospitalization and medication/s or
treatment/s given.

Developmental History of the Child

This section must include the following:

1. The developmental milestones which the child achieved in terms of fine/gross motor
skills, (e.g. age when the child started to hold head up, roll over, crawl, stand, walk,
grip, grasp, scribble, write, etc.)

emotional development (e.g. age when child started recognizing familiar faces, cries
when custodian leaves, shows desire to be held, and develop emotional attachment to
the custodian)

social development (e.g. age when the child started to smile, play alongside other
children),

and cognitive development (e.g. age when child was able to follow instructions,
respond appropriately to stimulation/s) prior to and after admission.

Speech and language development, indicate the age when the child started babbling,
and talk in single words, phrases, and sentences.

(Note: Information on the child’s developmental achievement is important as this will

help determine if the child’s development is within normal limits. There should be a
baseline assessment of what the child can do at the time of admission so that the
prospective adoptive parents would see the child’s progress.)
 2. If the child lived with the birth mother, stayed with relatives, guardians, or child
caring agency, indicate length of stay and developmental achievements prior to
placement to custodian;

3. Information whether the child is toilet trained or undergoing toilet training must be
included. If the child is on toilet training, information about the progress must be
specified (e.g. child can tell if he/she is wet; can sit on the potty; can indicate if
he/she needs to go to the comfort room).

4. For a child four (4) years old and above, include information on their interests,
preferences, favorites, daily activities, things that are important to them.

5. For a child five (5) years old and above (and if applicable), summary of the result of
psychological evaluation including recommendations, if any, of the psychologist for the
child.

6. For a child with developmental delay, result of developmental/neurodevelopmental

evaluation and actions taken to address the developmental pediatrician’s
recommendation.

Current Functioning of the Child-

For clarity, information in this section should be presented based on the following
developmental aspects (e.g. Physical, emotional, social, psychological, cognitive functioning).

For the physical aspect, indicate current height and weight.

For the emotional and social aspect, include how the child relates to other children,
custodians, strangers, or whether the child developed emotional attachment to a specific
person in the child caring agency. What makes the child happy/sad? What does the child do
when frustrated/angry? Is the child able to regulate his/her emotions on his/her own? Is the
child able to express himself/herself freely or does he/she need coaching/encouragement to
open up? Is the child able to talk about his/her feelings? How is the child pacified? What
discipline method works best for him/her? Does the child have any behavioral concerns that
the adoptive parents need to know? How do the custodians/significant adult/s handle the
child’s behavior?

Description of the child’s personality, hobbies, and interests.

For the psychological aspect, strengths and weaknesses of the child, level of confidence and
self-esteem, ability to deal with frustrations/challenges, methods/ways of learning of the
child. For educational aspect, include grade level, academic performance, and subjects where
he/she excels at or needs improvement. The teacher’s perspective on the child’s academic
performance should be discussed.

For a child/ren attending play, occupational or speech therapy, information must be included
as to the progress of the child resulting from the intervention/s.

For children ages 5 years old above

1. What are the child’s interests, strengths, and favorite past time/s?
2. What are the things that are important to the child (e.g. favorite toys, time with the
custodian, to have parents, etc)?
3. How is the child connected to the community outside of the CCA/foster home?
4. What is the child’s primary language and is he/she can converse and understand other
languages?
 5. What is the child’s understanding of his/her origin and present situation? Was he/she
informed about why he/she is in the CCA/foster home? How does he/she feel towards
his/her biological parents? What interventions are provided to address any unresolved
feelings?
6. What are the child's attitudes, feelings, and thoughts about adoption? How does the
child feel about having a family? What is a family for the child? Let the child describe
his/her idea about the members of a family.
7. What does the child look forward to in the future, wishes, aspirations, and dreams for
himself/herself?
8. What makes the child happy/sad? How does the child manifest emotions? Please give
a description of the child’s mode of expressions (e.g. when angry, what does the child
do? How is the child pacified?)
9. What is the child’s attitude towards discipline and correction? What behavioral
modification or method of discipline is currently applied to the child? What works best
for the child in terms of discipline and correction?
10. Is the child able to spontaneously express his/her feelings or does he/she need
coaching or encouragement to open up? How does the child express his/her feelings?
11. How does the child relate with other children in the child caring agency? Who is the
child’s best friend?
12. How does the child perform in school? How does the child relate to his teachers and
classmates?
13. If the child has a sibling, how is his relationship with him/her?
14. If the child is for inter-country adoption, what is the child’s understanding of life
abroad? To minimize frustration or adjustment difficulty, the child should be informed
of the realities of adoption and life abroad. The child must be made aware that the
ultimate purpose of adoption is to have a family to care and love instead of gaining
material things.
15. Who is the child’s primary attachment figure, if any? Please describe the interaction or
relationship between the child and the primary attachment figure.
16. How does the child relate with the children in the center or foster home? Who are the
child’s playmates – younger or older than himself/herself?
17. Do you see the child correcting other children? How does the child correct his/her
peers or younger children? When does the child correct his/her peers or other
children?
18. What is the child’s understanding of respecting adult authority, rights of others,
personal space, rules, right from wrong, cause and effect or consequences of actions?
Please provide examples.
19. What is the child’s persistent behavioral issues/concerns that the prospective adoptive
parents need to know (e.g. bedwetting, telling lies or making up stories, getting things
without permission, talking back when reprimanded or corrected, being aggressive
when he/she does not get what he/she wants, blaming others to avoid correction,
difficulty accepting mistakes and taking responsibilities for her mistakes, etc.)? For
any behavioral issue/concern noted, please indicate how it is handled by the
custodians.
20. What is the child’s usual emotional state (i.e., frightened, excited, sad, etc.)? What
incidents would trigger these emotions? What does the child do when such emotions
occur? How does the custodian handle such outburst of emotions?
21. What are the child’s fears? Does he/she express his/her fears? What could be the
basis for his/her fears? How are these addressed?
22. Does the child display aggression towards other children, adults, animals? What
aggressive behaviors are seen and what triggers such? What does the child do when
in an aggressive state (e.g. hits back, throw things…etc.)?
23. Is the child able to concentrate or complete a task? Record how long the child can
sustain attention to a specific task/activity and what the child does when distracted? If
the child has difficulty concentrating on a task, note the time the task/activity is given,
the child’s interest to the activity/task, the companion of the child, understanding of
the task/activity and what is expected of him/her.

Description of the Child's Present Environment - This includes the following information:

 Present Address of the Child (Name of barangay, municipality, town, or city)

  Name of guardians including basic demographic information such as age, occupation,
civil status, relationship to the child, etc.
 Description of the home and community (Please include home style, appliance

 When was the child placed with the current guardian?

 If child is in foster care, include information on the sleeping arrangement in the foster
home.

A. THE FAMILY- This tackles the composition and pertinent background information on
biological family such as:

● Name and date of birth

● Physical description of the family, such as physical appearance of birthmother/father,

body build, height, complexion, hair, eyes, nose and disability/deformity (if any).
● Health history (physical and mental such as hereditary/non-hereditary illness/es,
medications taken, etc.) For the birth mother, include pre-natal history.
● Education/occupation/income and earnings

● Personality, psychological and emotional make-up of the birth parent such as:

1. Character/trait/how he/she is as a person

2. Hobbies, interests, talents
3. Quality of intra-familiar relationship, family dynamic (nature of marital relationship
of birth parents, birth parents’ relationship with their children and siblings
relationship)
4. Information on the birthparents, such as number of their siblings and their
relationship with each other; how the parents met, and if they were married or
not, etc. If they have medical illnesses, medication that they took and if such
illnesses hinders/affects their parental capability should be specified in the report.
If a parent is detained in jail, the status of the case filed should be stated.
5. Childhood experiences of birthparents (positive/negative that may have an impact
on quality of parenting assessment of mental ability and level of
intelligence/personality)
6. Negative history of substance/alcohol abuse, sexual abuse, domestic violence,
imprisoned parents/criminal record.

If the birth mother has history of substance abuse while pregnant, indicate the
frequency, duration, and amount of substance consumption.

7. Birth parent’s attitude towards the child during the time that he was still in her
care.

For birth parent/s with history of counseling, psychiatric/psychological treatment,

indicate the reason for the counseling or psychiatric/psychological treatment,
name of institution where the services were availed, name of psychologist or
psychiatrist. A psychological/psychiatric report should be included in the child’s
dossier.

IV. (TERMINATION OF PARENTAL RIGHTS/FACTS OF ABANDONMENT)

1. What circumstances led to the birth mother’s decision to relinquish the child?

2. Assistance rendered to the birth parents- Poverty cannot be accepted as a sole reason
for surrendering the child for adoption. Therefore, case management requires that in
 response to circumstances influencing the decision of the parents to relinquish their
parental authority, an appropriate service/s should be provided. The reasons for the
failure of these services from assisting the parents to achieve this goal should be
clearly stated in the report.
3. For victims of rape, counseling services must include goals to help the birth mother in
overcoming the trauma brought by sexual abuse and regaining feelings of security
and worth. Please specify the intervention provided to help the birth mother recover
from the sexual abuse. Include information on the current whereabouts and situation
of the birth mother.
4. How does the birth mother and her family members feel about relinquishing and being
separated from the child? Does the birth mother and her family understand the
implications of relinquishing the child?
5. If the birth of the child is unknown or the birth mother refuses to divulge the child’s
birth to her family members, what efforts were taken to convince the birth mother to
inform her family members? The UN guidelines on the care of children needing
alternative parental care states that all hindrances to reunification should be
eliminated.
6. Date when the birth parent/s signed the Deed of Voluntary Commitment (for IP/Direct
Entrustment Case)/Affidavit of Consent (for Relative/Step-Parent Case) to Adoption
and date if was notarized. (A valid ID of the parent/s should be presented before the
notary public).

(FACTS OF ABANDONMENT- for child without known parents for IP/Direct Entrustment
Case)

1. Cite the circumstances on how the child was found, such as WHO found the child, WHERE
was the child found, WHEN was the child found, approximate age of the child when found,
WHAT was the condition of the child when found, HOW the finder facilitated placing the
child to a child caring agency or office.

If newborn, describe the physical appearance of the child (umbilical cord still intact,
cleaned-up, bluish, with discoloration, with placental scums, wrapped in baby blanket,
towel etc.)?

2. Depending on the age of the child, include the following:

• Identifying information (e.g. name, date of birth)
● Who brought the child to the place where he/she was found?
• What was the child doing in that place?
• Who are the companions of the child?
• What is the relationship of the child to the companions?
• How did the child get to that place?
● What are his/her recollection of birth family/siblings (e.g. name of parents, siblings,
address?
3. Efforts exerted by the social worker to locate the whereabouts of the birth
parent(s)/family (indicate the date of media certification, newspaper publication, blotter
reports, registered mail, etc.).
4. Site visit to the place where the child was found.
5. On the finder, include basic demographic information. How did the finder find the child?
How did the finder determine that the child was abandoned? What did the finder do after
finding the child (e.g. reported to the authorities)?

B. ON THE PAPS

I. APPLICANT/S IDENTIFYING INFORMATION

Female PAP Male PAP

Complete Name
(First, Middle and
 Last name)
Date of Birth
Place of Birth
Height
Weight
Religion
Civil Status (date
and place of
marriage, if
applicable)
Citizenship
Language/s
spoken
Education
Occupation
Mobile Phone
Home Phone
number (landline)
Work Phone (if
applicable)
E-mail address (if
applicable)
Employer
Employer address
and contact details
Monthly Income
Other sources of
income

Dates of contact:

Date Person/s Length of Interview Location of Interview

Interviewed (Hours and
Minutes)

II. FAMILY COMPOSITION & OTHER INDIVIDUALS LIVING WITH THE APPLICANT/S

Name Age Relationship Educational Occupation Disability/

to the client Attainment sickness (if any)

III. FAMILY BACKGROUND INFORMATION/DESCRIPTION OF THE APPLICANT/S: This

should include information about the applicant’s parents and siblings, childhood experiences
of the couple and how they were reared by their family and significant others in their lives. It
should also include information on the discipline pattern of the family including sensitive
areas such as history of child abuse, alcohol and substance abuse and their corresponding
sanctioning penalties, vices and coping mechanisms in handling stress/crisis and conflicts.
Further, it should consider the applicants’ physical description and personal traits, social
relationships, and educational history.

IV. MOTIVATION TO ADOPT AND CHILD PREFERENCE: This should address reason/s for
wanting to adopt, who, when, how the decision was arrived at; attitude and resolution of
feelings towards infertility, if applicable. Child preference should be in terms of age,
characteristics, and the extent of physical, medical, and mental capacity of the child
acceptable to the applicant/s and the reason/s for such preference.
 V. CHILD CARE AND GUARDIANSHIP PLANS: This should include information on the length
of parental leaves, if applicable, day to day care of the child, childcare arrangement after the
parental leaves, education of the child as well as how the applicant/s will manage caring for
the adoptive child and other life commitments such as work.

The attitude of the extended families and friends should be indicated, future plans, if any, for
the child are to be included.

VI. MARITAL HISTORY/RELATIONSHIP: This section should include the following

information: nature and extent of marital relationship, patterns of resolving conflict,
annulment history/ discussion of circumstances and relationship, children from previous
marriage/s with whom they are currently living, current family relationships particularly
husband/wife, parent/child, sibling, and their extended families.

Children in the family - Description of the children, their significant traits and
characteristics, their role in the home and their preparation for the coming of another child,
their feelings, and attitudes towards adoption. Indicate if biological or adopted, date/s of
birth, age/s, description of characteristics, educational attainment.

Previous history of adoption disruption if any

Other individual/s living at the home - Descriptive paragraph of every person living in
the home should also be included, adult family members should be asked the same questions
re: substance abuse, sexual or child abuse and their responses discussed.

The attitude of Immediate Family Members Regarding Adoption: This should include
information on whether the adoption plan was discussed with the extended family members
of the applicant/s, thoughts, and attitude of the extended family members on the adoption
and their involvement with the adoptive child after placement

VII. PARENTING AND CHILD CARING EXPERIENCE: The couple’s experience in taking care of
a child/ren whether on temporary or prolonged basis should be indicated. Their past
experience in parenting and/or knowledge of childcaring as well as their expressed
disposition and attitude towards discipline patterns, ability to provide nurturing care and
supervision in an atmosphere of affection and moral and material security should be
indicated.

VIII. EMPLOYMENT HISTORY/FINANCIAL RESOURCES: The employment history of the

applicant/s should indicate reasons why they moved or changed work. Provide a short
description of the source/s of income, savings, investments, expenditures, and liabilities, if
any, and insurance/s.

IX. DESCRIPTION OF HOME AND COMMUNITY: The home study should describe the family’s
home, child’s accommodation, membership and participation in community organizations,
community projects and activities. Community resources and specialized facilities for children
such as hospitals, clinics, schools, etc. should be included in the report. Indicators should be
given on the degree of racial tolerance and how this may affect the adjustment of the child in
the community.

X. SOCIAL ETHNO-CULTURAL, LINGUISTIC AND RELIGIOUS IDENTITY OF THE

APPLICANT/S: Spiritual/philosophical/moral beliefs, affiliations, and practices

XI. HEALTH HISTORY (Physical and Psychological): Applicant/s should indicate any serious
illness, physical disabilities, or history of mental illness, if any. A medical report on the
family’s health status and health history should be discussed. To also include the result of the
police/NBI clearances.

Psychological evaluation report (if recommended by the adoption social worker): This
should include information on the psychometric tests done, results of the tests and clinical
interviews, assessment summary and recommendation/s of the psychologist.
XII. CHARACTER REFERENCES: Source of information are from three (3) persons not related to
the applicant/s by consanguinity or affinity but who have known them for at least three (3)
years. Information should include the references’ impressions on the applicant/s’ relationship
and family life, nature of involvement with children, parenting styles (if applicable).

XIII. TRAINING ATTENDED/COMPLETED, IF APPLICABLE OR THE APPLICANT/S

KNOWLEDGE AND AWARENESS ABOUT ADOPTION:

For applicant/s who have undergone pre-adoption trainings, include the title of the trainings,
number of hours, topics discussed and insights/learnings of the applicant/s.

For applicant/s with no formal pre-adoption trainings, include information on their knowledge
and understanding of adoption and its process and requirements, challenges associated with
adoption, costs of adoption, learnings from friends or relatives and/or from reading adoption
books/materials.

XIV. ADOPTION TELLING AND POST ADOPTION ISSUES: This includes the applicant/s plan
on how they intend to tell the child about his/her adoption story, the applicant/s opinion on
the issue of adoption search and reunion with the birth family.
C. ADOPTION PLACEMENT

I. PLACEMENT HISTORY (for IP/Direct Entrustment Case)

Date of Matching
Name of RACCO/CPA
Date Accepted by PAPs
Date of Placement
Age of Child upon placement

II. Description of the child upon placement to the PAP/s:

III. Medical condition of the child upon placement

IV. Developmental achievements of the child upon and after placement

V. Current functioning of the child

VI. Supervised trial custody report

VII. ASSESSMENT- Summary statement on the progress of the placement focusing on the
developmental achievements of the child since placement, adjustment of the child in the
PAPs home, adjustment of the PAPs and their children, if any, to the adoptive child,
acceptance of the child by the PAPs extended family members, and overall changes to the
PAPs family after the placement.

VIII. RECOMMENDATION- Summary statement indicating the social worker’s

recommendation on the placement.

Prepared By: Approved by:

(Signature) (signature)
(Name of Social Worker) Name of Head of Office
(License Number and Validity Date)