IAV Mandatory Questionnaire and Child Profile Form · Web viewShould you wish to proceed, you need...

Intercountry Adoption Victoria Questionnaire

Contents

Background information.............................................................................................................................................. 2Children information.................................................................................................................................................... 3Children not living with you......................................................................................................................................... 4Criminal records/court orders/driving history...............................................................................................................5Religion....................................................................................................................................................................... 6Physical and psychological health.............................................................................................................................. 7Fertility...................................................................................................................................................................... 12Physical and psychological health............................................................................................................................ 14Fertility...................................................................................................................................................................... 19Child profile............................................................................................................................................................... 21IAV............................................................................................................................................................................ 22Finances................................................................................................................................................................... 23Referees................................................................................................................................................................... 23Guardian................................................................................................................................................................... 23Child profile form....................................................................................................................................................... 24

DHHS Date Stamp on Receipt: DHHS Identification Number:

Dear prospective applicants to the Intercountry Adoption Victoria (IAV) Victoria,

The information sought in this questionnaire, will be treated with utmost privacy. Please type your responses to the questions, print out the form, sign and date it and send to IAV by post:

IAV Level 20/570 Bourke Street, Melbourne VIC 3000.

Please take the time to fill in all of the questions. Should you wish to proceed, you need to return both the completed questionnaire and child profile form.

Please note that some of the information required to establish your eligibility for the IAV program such as medical reports, driving history, financial statements etc may incur additional fees. It is the responsibility of any prospective applicant to meet these costs.

Should you have any questions or require any assistance, please telephone the Duty Worker at IAV on (03) 8608 5700 or by email to <[email protected]>

The Department of Human Services Privacy Policy is available at: <https://dhhs.vic.gov.au/publications/privacy-policy>

https://dhhs.vic.gov.au/publications/privacy-policy

https://dhhs.vic.gov.au/publications/privacy-policy

mailto:[email protected]


Background informationMale applicant Female applicant

Full name

Date of birth

Place of birth

Citizenship

Ethnicity

Highest level of education attained

Occupation

Address

Contact phone numbers

Home:

Work:

Mobile:

Email address(s) confirmation

Marriage details

[Please mark with an ‘x’ or fill in as appropriate]

Are you married? Yes No

If yes please give date of marriage

If in a de facto relationship, please give date of commencement of relationship

Date(s) of previous marriage(s) (if applicable)

Date(s) of Divorce(s) (if applicable)

IAV questionnaire and child profile form 2

Children information

Child 1

Name

Date of birth

[Please indicate below if your child is]

Birth Adopted Fostered Step Child

Does this child attend school?

Yes No Year Level?

Is this child home schooled? Yes No

Child 2

Name

Date of birth




Yes No Year Level?


Child 3

Name

Date of birth




Yes No Year Level?


Child 4

Name

Date of birth




Yes No Year Level?



Children not living with you[Please indicate children of former relationships, marriages and deceased children]

Child 1

Name

Date of birth

Custodian / guardian where relevant

How often do you see this child?

Child 2

Name

Date of birth



Child 3

Name

Date of birth



Child 4

Name

Date of birth




Criminal records/court orders/driving history

Criminal Record

[Please indicate if a criminal records check will show a charge or conviction of ANY nature over the last 10 years]

A criminal records check will show a charge or conviction? Yes No

[If Yes then please summarise the nature of the offence and conviction]

Driving history

For China programs (mainstream and special needs) you will need to provide your full driving history. You will need to telephone VIC ROADS to request your full (lifelong) driving history. Please note this is not the 5 year traffic history available online. Please attach a copy of the record to this Questionnaire. (Be aware 5 traffic infringements renders one ineligible for these programs.)

A copy of the record of full driving history is attached Yes No

Intervention orders

[Please indicate if any person has a past or current intervention order against you, both applicants]

Applicant 1

Past or current intervention order against applicant Yes No

Applicant 2

Past or current intervention order against applicant Yes No

[Please indicate if you have taken out an intervention order against another person ]

Have taken out an intervention order against another person Yes No


Police attendance

[Please indicate if police ever attended your home in relation to a domestic dispute or family violence

Police have attended home in relation to a domestic dispute or family violence

Yes No

[Please give details]

Religion[Please indicate your precise religious affiliation – both applicants. I.e. Catholic, Jehovah Witness, Baptist, etc]

Applicant 1

Religious affiliation

Applicant 2

Religious affiliation

[Please outline your level of commitment to your religious faith/church. For example: Non-practising, practicing and regular church goer, practicing and heavily involved in your faith, community

Applicant 1

Level of religious commitment

Applicant 2

Level of religious commitment

If you were interested and eligible to adopt from either Taiwan or the Philippines, you are required to be a practising mainstream religious Christian.

[Would you be able to provide a written reference from a priest or minister who could comment on your involvement in your faith community? If not applicable please select Not Applicable.]

Applicant 1

Provide written reference from religious leader

Yes No Not applicable

Applicant 2

Provide written reference from religious leader

Yes No Not applicable


Physical and psychological health

Applicant 1

Height (cm) Weight (kg) BMI

You can calculate your Body Mass Index (BMI) by visiting Better Health [https://www.betterhealth.vic.gov.au/health/healthyliving/body-mass-index-bmi]

Please note several countries require applicants to have a BMI of 30 or less. IAV also considers an applicant’s BMI together with cholesterol, blood pressure and other indicators of weight related health issues

Do you consider yourself to lead a healthy lifestyle? Yes No

Do you exercise regularly? Yes No


Do you smoke? Yes No

[If Yes please detail number of cigarettes per day and length of time as a smoker ]

Have you ever smoked? Yes No

[Please indicate length of time as a smoker, volume per day and when and how you successfully quit.]

Do you consume alcohol? Yes No

[If Yes please detail volume and frequency of consumption.]

Have you ever smoked marijuana or used other illicit drugs? Yes No

[If Yes how often and when did you cease]


https://www.betterhealth.vic.gov.au/health/healthyliving/body-mass-index-bmi

Has a proposal for life or accident insurance ever been rejected, deferred or withdrawn?

Yes No

[If Yes please give details]

Are you in receipt of a pension/benefit or have you received any form of compensation or payout relating to injury or illness of any kind?

Yes No

[If Yes please provide details]

Are you currently on any form of medication? Yes No

[If Yes please list medication, how long you have been taking it, the condition it is treating and the name of the doctor prescribing this medication]

Have you previously required any form of long term medication?

Yes No

[If Yes please detail the medication, length of time taking it, the condition being treated and the name of the doctor prescribing this medication]

Have you ever or are you currently being treated for any conditions, such as those listed below? If you answer Yes to any of them, please add some detail to assist us in understanding your current prognosis relating to the condition. If you are being treated for any condition not mentioned below, please add the name and details of the condition and treatment under the section titled ‘other’.

High blood pressure/high cholesterol Yes No


<Please provide details>

Any other cardiovascular disease Yes No


Any form of lung disease including asthma, chronic bronchitis

Yes No


Tuberculosis Yes No


Indigestion, gastric or duodenal ulcer Yes No


Bowel disease, passage of blood from the bowel Yes No


Liver or gall bladder disease Yes No


Epilepsy, or fits of any kind Yes No


Fainting attacks Yes No



Psychological or nervous disorder,depression, psychiatric disorder or attempted suicide

Yes No


Kidney or bladder disease, including renal colic, blood in the urine

Yes No


Diabetes Yes No


Gout Yes No


Cancer or tumour of any type: malignant or benign Yes No


Impairment, numbness, deformation or removal of limbs Yes No


Arthritis or muscular related disorder Yes No


Defects in sight, speech or hearing Yes No



Haemophilia Yes No


Cystic fibrosis disease Yes No


Huntington’s disease Yes No


Parkinson’s disease Yes No


Hepatitis B/C Yes No


Chronic fatigue syndrome Yes No


Organ transplantation. Please give date of transplant Yes No


Crohns or Celiac disease Yes No



Lupus /SLE Yes No


OTHER - Any other illnesses, injuries or operations not listed above

Yes No


Have you ever been advised to have an operation Yes No


Do you contemplate surgery in the future? Yes No


For persons over the age of 50 years have you had bowel screening? Should you be invited to make application you will need to provide results for the bowel screening tests as a requirement of the medical

Yes No


FertilityHave you previously been tested, and received a diagnosis and or treatment for infertility? If YES please give a summary of diagnosis and treatment history

Yes No


Are you currently undergoing any form of fertility treatment? If YES please detail including the name of the doctor overseeing your treatment

Yes No



Have you completed your fertility treatment? Yes No


Are you pregnant at the moment? Yes No


Are you pursuing Intercountry Adoption prior to exploring your fertility?

Yes No


If you were invited into the IAV service today, would you be ready to proceed?

Yes No



Physical and psychological healthApplicant 2

Height (cm) Weight (kg) BMI

You can calculate your Body Mass Index (BMI) by visiting Better Health [https://www.betterhealth.vic.gov.au/health/healthyliving/body-mass-index-bmi]

Please note several countries require applicants to have a BMI of 30 or less. IAV also considers an applicant’s BMI together with cholesterol, blood pressure and other indicators of weight related health issues

Do you consider yourself to lead a healthy lifestyle? Yes No

Do you exercise regularly? Yes No


Do you smoke? Yes No

[If Yes please detail number of cigarettes per day and length of time as a smoker ]

Have you ever smoked? Yes No

[Please indicate length of time as a smoker, volume per day and when and how you successfully quit.]

Do you consume alcohol? Yes No

[If Yes please detail volume and frequency of consumption.]

Have you ever smoked marijuana or used other illicit drugs? Yes No

[If Yes how often and when did you cease]


https://www.betterhealth.vic.gov.au/health/healthyliving/body-mass-index-bmi

Has a proposal for life or accident insurance ever been rejected, deferred or withdrawn?

Yes No

[If Yes please give details]

Are you in receipt of a pension/benefit or have you received any form of compensation or payout relating to injury or illness of any kind?

Yes No

[If Yes please provide details]

Are you currently on any form of medication? Yes No

[If Yes please list medication, how long you have been taking it, the condition it is treating and the name of the doctor prescribing this medication]

Have you previously required any form of long term medication?

Yes No

[If Yes please detail the medication, length of time taking it, the condition being treated and the name of the doctor prescribing this medication]

Have you ever or are you currently being treated for any conditions, such as those listed below? If you answer YES to any of them, please add some detail to assist us in understanding your current prognosis relating to the condition. If you are being treated for any condition not mentioned below, please add the name and details of the condition and treatment under the section titled ‘other’.

High blood pressure/high cholesterol Yes No



Any other cardiovascular disease Yes No


Any form of lung disease including asthma, chronic bronchitis

Yes No


Tuberculosis Yes No


Indigestion, gastric or duodenal ulcer Yes No


Bowel disease, passage of blood from the bowel Yes No


Liver or gall bladder disease Yes No


Epilepsy, or fits of any kind Yes No


Fainting attacks Yes No



Psychological or nervous disorder,depression, psychiatric disorder or attempted suicide

Yes No


Kidney or bladder disease, including renal colic, blood in the urine

Yes No


Diabetes Yes No


Gout Yes No


Cancer or tumour of any type: malignant or benign Yes No


Impairment, numbness, deformation or removal of limbs Yes No


Arthritis or muscular related disorder Yes No


Defects in sight, speech or hearing Yes No



Haemophilia Yes No


Cystic fibrosis disease Yes No


Huntington’s disease Yes No


Parkinson’s disease Yes No


Hepatitis B/C Yes No


Chronic fatigue syndrome Yes No


Organ transplantation. Please give date of transplant Yes No


Crohns or Celiac disease Yes No



Lupus /SLE Yes No


OTHER - Any other illnesses, injuries or operations not listed above

Yes No


Have you ever been advised to have an operation Yes No


Do you contemplate surgery in the future? Yes No


For persons over the age of 50 years have you had bowel screening? Should you be invited to make application you will need to provide results for the bowel screening tests as a requirement of the medical

Yes No


Fertility

Have you previously been tested, and received a diagnosis and or treatment for infertility? If YES please give a summary of diagnosis and treatment history

Yes No


Are you currently undergoing any form of fertility treatment? If YES please detail including the name of the doctor overseeing your treatment

Yes No



Have you completed your fertility treatment? Yes No


Are you pregnant at the moment? Yes No


Are you pursuing Intercountry Adoption prior to exploring your fertility?

Yes No


If you were invited into the IAV service today, would you be ready to proceed?

Yes No



Child profile

From which country/ies are you interested and eligible to adopt a child?

[Please mark with an ‘x’ as appropriate]

Bulgaria Chile China (mainstream)

China (special needs) Colombia Hong Kong

Latvia Philippines Poland

South Africa South Korea Sri Lanka

Thailand Taiwan (CSS) Taiwan (CWLF)

What aged child are you interested in adopting?

[Please mark with an ‘x’ as appropriate]

0 to 3 years 4 to 6 years 7 and over years

Do you have any parenting experience? Please outline. If YES would you consider adopting siblings?

Yes No


What are you able to offer an adopted child? Yes No


Are you aware that the children requiring adoption from overseas countries have a range of special needs this usually means a child with on-going medical and psycho-social issues

Yes No


It is important to understand that the complex special needs adoption programs should not be viewed by applicants as a way of expediting the adoption process; rather the purpose is to match children with

significant and on-going needs to parents whohave the capacity and resources to take on their care.

Please take time to look at the attached ‘special needs’ child profile and complete.For information on the types of medical conditions that are typical of the ‘special needs’ program, visit the

love without boundaries website< http://www.lovewithoutboundaries.com/adoption>


http://www.lovewithoutboundaries.com/adoption

IAVIt is your responsibility to ensure you have read and understood all information in respect to the Intercountry adoption program. It is very important that you do so as country program changes occur rapidly and may affect your eligibility.

Have you read the current IAV information kit Yes No

Have you completed the self-assessment tool on the IAV website

Have you attended an IAV Information Session? If so, when and where did you attend?

Yes No


Have you read and are you able to comply with the IAV policies?

Yes No


IAV prepares and places updated information on the IAV website regularly. We recommend that you read this for additional program information and updates.

Have you read the IAV website? Yes No


Are you aware of the foster care and/or Permanent care programs for children within the Victorian system?

Yes No

Is this something that you would consider? Yes No

Have you made any enquiry regarding local adoption? If YES please give detailsIf NO Please outline reasons why

Yes No



FinancesMost countries require applicants to provide information that will support their ability to provide financially for a child placed in their care through adoption. (The cost of adopting children from individual countries varies considerably, with the range being between $US 5,000 up to $US 20,000. Country programs have additional and specific financial requirements. Please ensure you familiarise yourself with these before proceeding.

Are you in a secure financial position to afford your Intercountry Adoption plans?

Yes No

Are you able to provide information about your assets and liabilities? E.g; bank statements, payslips etc

Yes No

Are you willing to have your financial position endorsed by a Certified Practicing Accountant?

Yes No

RefereesIAV will require you to provide the name and addresses of your references so that IAV can contact them directly to seek a reference on your behalf. You will be required to provide the names and addresses of two references (One family member for each applicant) and two referees (one for each applicant) from a friend.

Are you in a position to provide this information in the future?

Yes No

GuardianIAV require all applicants to be able to name a Guardian as a result of a catastrophic event. The Guardian needs to be someone that will have regular and ongoing contact with your adopted child, share parenting and lifestyle ideals and be of a similar age range. It is not in a child’s best interest to have a grandparent as a Guardian as it will be envisaged that they will not be able to fulfil all the requirements of parenting a young child.

Are you able to provide a suitable Guardian for your adopted child?

Yes No

We/I have read and understood all IAV information and we are/I believe eligible to proceed.

Applicant 1

Signature Date

Applicant 2

Signature Date


Child profile formAll children placed through Intercountry Adoption are considered to have special needs. Some of the more tangible medical and background factors are highlighted in the list below. However, in addition to these; all children placed through the Intercountry Adoption program will have a background of trauma and loss; children who have been in institutional care, or have experienced multiple family or foster carers will be particularly vulnerable and insecure.

Trauma and loss can be exhibited through behaviours considered challenging such as screaming, hitting, biting, stealing, rejection, withdrawal, hoarding food, difficultly settling to sleep and many others.

As a prospective adoptive parent you understand that attachment and bonding will be difficult where children have not had the benefit of a consistent, nurturing carer at the most critical time(s) in their emotional and physical development. You understand that the lifelong impact of abandonment/relinquishment and adoption together with the internalised manifestations of trauma and loss are uniquely present in the lives of all intercountry adopted children. The tangible medical and background issues listed below present additional challenges/special needs for both the child and their adoptive parents.

This Child Profile form helps us to understand your capacity. It will be used as a tool for discussion. Please mark with a ‘X’ where you feel you do have the capacity to be considered.

Please note some groupings/conditions will not be relevant to some country programs.

Applicant 1

Family name

Signature Date

Applicant 2

Family name

Signature Date


Child’s age

(NB If you are part of a targeted intake - Please select the age range for which you were invited to make application)

[Please mark with an ‘x’ where you do have the capacity to be considered]

Under 3 years

4 to 6 years

7 and over years

Sibling status

Single child

Sibling group of two

Sibling group of more than two

Family status

No known information

Parental history of drug dependency

Parental history of alcohol dependency

Parental history of emotional illness

Parental history of criminal record

Parental history of mental illness

Parental background of intellectual disability

Child conceived as a result of incest

Child conceived as a result of rape

Child’s health

Premature

Imperforate anus

Haemangioma

Nevus

Burn scars

Albinism

Female circumcision


Eye conditions

Sight in one eye

Partially blind

Legally blind

Strabismus

Crossed eyes

Eye squint

Ptosis

Glaucoma

Mouth/oral conditions

Cleft lip and palate

Ear conditions

Partial hearing

Total deafness

Deformed ear/s

No physical ears

Developmental delays

Cerebral palsy

Down syndrome

Foetal alcohol syndrome

Gross motor delay

Hydrocephalus

Failure to thrive

Intellectual disability

Seizure disorders

Moderate development delay

Global developmental delay

Speech delay

Spina bifida

Heart problems

Heart murmur

Heart defect


Hernias

Undescended testes

Hernia

Umbilical hernia

Infectious diseases

Positive TB screen

Positive VDRL -congenital syphilis

Positive hepatitis B screen/carrier state

Positive HIV/AIDS

Orthopedic problems

Congenital hip anomaly

Hand anomalies

Syndactity

Leg anomalies

Foot anomalies

Joined toes, missing or extra toes

Absent hand/s

Absent arm/s

Absent foot/feet

Absent leg/s

Walking difficulties

Wheelchair bound

Facial anomalies

Child’s emotional health and social development

Autism

Known history of physical abuse

Known history of sexual abuse


Please attach and list any personal or professional experience you may bring which highlights your ability to parent a child who has suffered significant trauma and loss:

<Please complete>

To receive this publication in an accessible format phone (03) 8608 5700, using the National Relay Service 13 36 77 if required, or email the Intake Team Duty Worker at AIV [[email protected]]Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, Department of Health and Human Services May, 2017.

Available at [email protected]




IAV Mandatory Questionnaire and Child Profile Form · Web viewShould you wish to proceed, you need...

Documents

Transcript of IAV Mandatory Questionnaire and Child Profile Form · Web viewShould you wish to proceed, you need...