___________________________________ gave your name to Adopt From Africa to contact as a reference. They are applying to be approved as an Adoptive Home. Please answer the following questions (that apply) to help us assess this family’s interpersonal skills and their ability to care for children. Please attach additional pages if necessary. When you have completed the form, please return it to:
Adopt From Africa
Austin, Texas 78720-0700
1. How long have you known the applicants, and in what capacity?
2. Have you ever been in the family’s home? How often, and under what circumstances?
3. Describe the family relationships in the home. How do family members relate to each other; spouse to spouse, parent to child, child to parent, child to child?
4. Describe how the applicants relate to others in the community. What activities are they involved in, how do they relate to the school, what are their communication/interaction skills?
5. Are you aware of this family (or individual members of the family) having any past experience in caring for children? In what capacity? Did they demonstrate any specific areas of strength or weakness? Please explain.
6. Describe the discipline the applicants use for their own children?
7. Indicate your observations regarding the physical or mental health of the applicants.
8. Are you aware of any drug or alcohol related problems the applicants, or any member of their family/household may have? Please explain.
9. Are you aware of incidents of child abuse or neglect in connection with the applicants, or any members of their family/household? Please explain.
10. Why do you (or do you not) feel this family can provide appropriate care to children?
11. What is your perception of this family’s commitment to Christ?
12. Do you have any further comments you wish to make regarding the applicant’s character or personality?
Thank you for responding to this reference request.
May we contact you in case any questions arise? Yes No