SAM HASLER

A TTORNEY AT L AW
1106 Meridian Plaza, Suite 251 Anderson, IN 46016

Telephone: 765-641-7906 Fax: (765)-374-3811

Web Page: http://samhasler.justia.net/index.html E-mail: samuelhasler@yahoo.com

ADOPTION QUESTIONNAIRE

The following questionnaire is designed to provide me with as much information as possible

needed to prepare an adoption petition. It is assumed that a step-parent is the person seeking to adopt
the child/children of their spouse.

Please answer each question as fully as possible. If any questions are inapplicable to you simply
indicate: "N/A". And, do keep in mind that any and all information provided me by you will remain strictly
confidential.

• Child's Name

• ___________________________________________________________

• Is the child male?

• ( ) Yes ( ) No

• Petitioner ‘s name (petitioner is the person adopting the child)

• ___________________________________________________________

• Petitioner's address

• ___________________________________________________________

• Petitioner's City

• ___________________________________________________________

Adoption Questionnaire Page 1 of 5

Provided by Samuel C. Hasler, Attorney
756-641-7906
• Petitioner's County

•( ) Madison
•( ) Delaware
•( ) Howard
•( ) Tipton
•( ) Grant
•( ) Other (not all choices have been listed):__________________________

• Date Petitioner Married

• ___________________________________________________________

• City where Petitioners married

• ___________________________________________________________

• State where Petitioners married

• ___________________________________________________________

• Petitioner’s Age

• ___________________________________________________________

• State Petitioner born

• ___________________________________________________________

• City where Petitioner born

• ___________________________________________________________

Adoption Questionnaire Page 2 of 5

Provided by Samuel C. Hasler, Attorney
756-641-7906
• Date Petitioner born

• ___________________________________________________________

• Petitioner’s employer

• ___________________________________________________________

• Petitioner’s job title

• ___________________________________________________________

• Child's race

• ( ) White
• ( ) African-American

• Child born in what State?

• ___________________________________________________________

• Child born in what city?

• ___________________________________________________________

• Child's age

• ___________________________________________________________

Adoption Questionnaire Page 3 of 5

Provided by Samuel C. Hasler, Attorney
756-641-7906
• Change last name only?

• ( ) Yes ( ) No

• New last name?

• ___________________________________________________________

• Do the clients want the full name changed? If so, what is it?

• ___________________________________________________________

• How long has child lived with petitioners?

• ___________________________________________________________

• Mother's name

• ___________________________________________________________

(If mother is the custodial parent, ignore this section of questions)

• Mom's parental rights terminated

• ( ) Yes ( ) No

• Court terminating mom's parental rights

• ___________________________________________________________

• Cause number for mom termination case

• ___________________________________________________________

• When was the last time mother had significant communication with child?

• ___________________________________________________________

Adoption Questionnaire Page 4 of 5

Provided by Samuel C. Hasler, Attorney
756-641-7906
• When was the last time mother paid child support?

• ___________________________________________________________

• Last known address for mother?

• ___________________________________________________________

• Father's name

• ___________________________________________________________

(If father is the custodial parent, ignore this section of questions)

• Dad's parental rights terminated?

• ( ) Yes ( ) No

• Court terminating dad's parental rights

• ___________________________________________________________

• Cause number of dad’s termination case

• ___________________________________________________________

• When was the last time father had significant communication with child?

• ___________________________________________________________

• When was the last time father paid child support?

• ___________________________________________________________

• Last known address for mother?

• ___________________________________________________________

Adoption Questionnaire Page 5 of 5

Provided by Samuel C. Hasler, Attorney
756-641-7906