China Eligibility Check





Adoption Information

Please write a brief message about why you would like to adopt. Be sure to include any relevant information such as Chinese heritage, adopting a Waiting Child (and any details pertaining to that such as a specific child on the list, medical condition and age), previous China adoption(s), etc

Mother - Detailed Information








Mother - General Health Information

Do you have any current diagnosed health conditions?
If yes, please provide the condition, date of diagnosis,
treatment, and prognosis:
Do you currently take any prescribed Medications?
If yes, please list the medication, the date originally prescribed,
and the reason for the prescription.
In the last two years, have you taken any medications typically prescribed for anxiety or depression? (ie: Celexa, Paxil, Xanax, Effexor, Wellbutrin, etc)
If yes, please list the medication, dates taken, and reason taken.
Have you had any operations?
If yes, please provide the type of operation, date, purpose, and outcome.


Have you ever been diagnosed with Cancer or Lupus?
If yes, please provide the date, type, treatment, and prognosis
Mother - Personal History Have you ever been diagnosed with depression or anxiety?
If yes, please provide the date and details of the diagnosis.
Have you ever seen a counselor?
If yes, please provide the date and reason for counseling.
Have you ever had and/or been treated for substance abuse or alcohol related issues?
If yes, please provide date and details.
Have you ever been the victim of emotional or physical abuse?
If yes, please provide date and details.
Have you ever given up parental rights?
If yes, please provide date and details.
Mother - Criminal History Have you ever been arrested or charged with any crime regardless of disposition or outcome?
If yes, please provide the details including:
offense, date of offense, date of sentence, sentence received,
time spent in jail, total fines, and description of circumstances.








Have you ever been reported to Child Protective Services?
If yes, please provide the date and details of the report.
Have your parental rights ever been terminated?
If yes, please provide the date and details.
Father - Detailed Information








Father - General Health Information

Do you have any current diagnosed health conditions?
If yes, please provide the condition, date of diagnosis,
treatment, and prognosis:
Do you currently take any prescribed Medications?
If yes, please list the medication, the date originally prescribed,
and the reason for the prescription.
In the last two years, have you taken any medications typically prescribed for anxiety or depression? (ie: Celexa, Paxil, Xanax, Effexor, Wellbutrin, etc)
If yes, please list the medication, dates taken, and reason taken.
Have you had any operations?
If yes, please provide the type of operation, date, purpose, and outcome.


Have you ever been diagnosed with Cancer or Lupus?
If yes, please provide the date, type, treatment, and prognosis
Father - Personal History Have you ever been diagnosed with depression or anxiety?
If yes, please provide the date and details of the diagnosis.
Have you ever seen a counselor?
Please provide the reason for counseling
Have you ever had and/or been treated for substance abuse or alcohol related issues?
If yes, please provide date and details.
Have you ever been the victim of emotional or physical abuse?
If yes, please provide date and details.
Have you ever given up parental rights?
If yes, please provide date and details.
Father - Criminal History Have you ever been arrested or charged with any crime regardless of disposition or outcome?
If yes, please provide the details including:
offense, date of offense, date of sentence, sentence received,
time spent in jail, total fines, and description of circumstances.








Have you ever been reported to Child Protective Services?
If yes, please provide the date and details of the report.
Have your parental rights ever been terminated?
If yes, please provide the date and details.
Family Information
Have you ever been divorced?
If yes, please indicate which spouse, the start and end date of
the marriage, and the reason for the divorce.



Children Status Do you currently have children?
If yes, please indicate the gender, age, and if they currently live with you.


Financial Information $

$

Is your net worth greater than $80,000?
If no, please describe the resources available to you to financially
provide for your child (family support, grants, community resources, etc):