Bethany Christian Services of

ADOPTIVE CHILD DISCLOSURE

Bethany Christian Services strives to provide prospective adoptive parents with relevant information in
its possession which it is able to share regarding the child and the birthfamily, unless prohibited by
applicable state and/or federal law.

Information in agency possession may be generated by other domestic and/or intercountry child
welfare agencies, governmental agencies, courts, or community professionals such as psychologists
and therapists. Bethany cannot attest to the accuracy or validity of such information.
***********************************************************************************************************
The following information was provided by Bethany Christian Services and discussed with
(Prospective Adoptive Parents). As adoptive
parents, we understand that this information is confidential and will be kept in a safe place to be
shared with our child at appropriate times.

Medical Reports (# pages) Yes No Not Available

Describe:
______________________________________________________________________
_____________________________________________

Birth Certificate Yes No Not Available/not applicable

Child Study/Social History Yes No Not Available/not applicable
Child Adoption Assessment Yes No Not Available/not applicable
Birthparents’ Social/Medical History Yes No Not Available/not applicable
Medical History Yes No Not Available/not applicable
Immunization Records Yes No Not Available/not applicable
Dental Reports Yes No Not Available/not applicable
Psychological Reports Yes No Not Available/not applicable
Psychiatric Reports Yes No Not Available/not applicable
School Records Yes No Not Available/not applicable
Individual Education Plan Reports Yes No Not Available/not applicable
Initial/updated Service Plans Yes No Not Available/not applicable
Caregiver/Foster Parent Reports Yes No Not Available/not applicable
Other (noted specifically) Yes No Not Available/not applicable

Having received the above indicated information, we will evaluate it with the assistance of appropriate
professionals. We do so knowing that it is neither all-inclusive nor complete, but represents the
information in the possession of Bethany Christian Services of
which it is lawfully authorized to share regarding the child and the birthfamily and which is in their
possession at the time of our signatures. Our dated signature(s) verifies receipt of the above indicated
materials.

Adoptive Mother Date

Adoptive Father Date

Bethany Social Worker Date

APPROVED: 9/13/04 by Leadership Team

Revised & Approved: Infant Adoption Project Team, International Adoption Project Team, Older Child Adoption Project Team
Approved: 8/19/09 by TQM Committee
Lkg/Policies/Program Forms/Adoptive Child Disclosure 2009.doc