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Adoptive Family Request For Information Form

We thank you for taking the time to provide the information below. After receiving your information, one of our experienced professionals will contact you to discuss our programs and answer your questions.

Check all that apply:
I am looking to:
 
Preferred Contact Method  
Please indicate your availability between the hours of 9:00 am - 5:00 pm, Monday through Friday)
Receive an informational packet
Adoptive Family
Ap 1 First Name*
Ap 1 Last Name*
Ap 2 First Name
Ap 2 Last Name
Leave blank if there is no Applicant 2 DO NOT enter “N/A”
Address
Street Address
Street Address Line 2
City
State/Region*
Enter Region
Zip Code
County
Contact
Phone
()-ext
Enter Int'l Number
Ap 1 Cell Phone
()-ext
Enter Int'l Number
Ap 1 Work Phone
()-ext
Enter Int'l Number
Ap 1 Email*
The sharing of a current email address is required. It is the client's responsibility to frequently check for emails from the agency.
Ap 2 Cell Phone
()-ext
Enter Int'l Number
Ap 2 Work Phone
()-ext
Enter Int'l Number
Ap 2 Email
The sharing of a current email address is required. It is the client's responsibility to frequently check for emails from the agency.
Length of relationship, Married or Unmarried
How were you referred to us?*  
Other


What type of child do you hope to adopt?
Minimum child age
 
Maximum child age
 
Open to twins?
Open to siblings?
Interested in adopting an older child (over the age of 2 years old)?
Interested in the A-OK Program?
Interested in Domestic Adoption?
Interested in a Step Parent Adoption?
Intake Interested in International Adoption:
Do you have any questions?
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Our mailing addresses and phone numbers are:

Main Office: 131 John Muir Dr. | Amherst, NY 14228 | 716-639-3900
Florida Office: 1600 S. Federal Highway, Suite 202 | Pompano Beach, FL | 33062 | 954-566-6055
Ohio Office: 7815 Cooper Rd., Suite E | Cincinnati, OH | 45242 | 513-631-3900

Regional Phone Numbers
Albany 518-391-2515 | Binghamton 607-330-2158| Rochester 585-672-5227 |
New York City 917-470-9340 | Syracuse 315-703-7511 | Poughkeepsie 845-457-4883|
Cleveland 216-201-9177 | Miami 305-433-8531

Call Toll Free 866-691-3300

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