Adoptive Parents Forms - The Cradle

If you are requesting:
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Checklist for Post
Adoption Services
Background History Report
Brief Update Report
Birth Parent Report
You will need to return
Fee Schedule (with payment if applicable)
Client Identification Form (signed)
Copy of valid photo identification
What Every Client Should Know
Letter (signed)
Privacy Acknowledgment Form
(signed)
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth family, optional for others)
Mutual Consent Registry
You will need to return
Fee Schedule (with payment if applicable)
Client Identification Form (signed)
Copy of Valid photo identification
What Every Client Should Know
Letter (signed)
Privacy Acknowledgment Form
(signed)
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth family, optional for others)
Information Exchange Authorization
Form (Notarized)
“Your first letter” (optional)
Search
You will need to return
Descendent of a deceased adopted person and the surviving
relative of a deceased birth parent must provide copy of death
certificate or obituary and proof of relationship for any
service request.
Fee Schedule (with payment)
Client Identification Form (signed)
Copy of Valid photo identification
What Every Client Should Know
Letter (signed)
Privacy Acknowledgment Form
(signed)
*Copy of Illinois Adoption Registry
Confirmation Letter
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth family, optional for others)
Information Exchange Authorization
Form (Notarized)
“Your First Letter”
Personal History & Biography
Questionnaire
(*Before requesting a Search, registration
with the State of Illinois is required. Go to
www.idph.state.il.us for forms.)
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2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Fee Schedule
Post Adoption Services
Your Full Name (please print): ___________________________________________________ Date: ________________
Requested Service(s)
Non-Identifying Information
Background History Report (DOB 1923-1940) $50
Fees
Background History Report (DOB 1941-present) $125
Registry
received background information) $50
Birth Parent Report (for Birth Parents only) $0
Registry with Medical Questionnaire $0
Registry without Medical Questionnaire $15
Reaching Out
Basic Search $225
Extended Search (if Basic Search is unsuccessful) $300
Reconnection $50
Brief Update (if you have previously
Counseling/Consultation
In person
By phone
Mediation at The Cradle
Community Services
Training
$110 (per hour)
$110 (per hour)
(Prorated by 1/2 hour)
$110 (per hour)
contact us for more information
Payment Method
Check made out to The Cradle enclosed
Total Fees:
Contribution:
Total Payment:
__________
__________
__________
If paying by credit card:
Name on Card:
Visa Card Number:
MasterCard Expiration Date:
Discover 3-digit Security Code on back of card ___________________________
Signature:
Current Address: __________________________________________
__________________________________________
FEES ARE NON-REFUNDABLE REGARDLESS OF OUTCOME.
FEES ARE SUBJECT TO CHANGE WITHOUT NOTICE!
For Office Use Only:
Date Received: ______________________________
Payment Received: ___________________________________
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2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Client Identification
Your Name (First, Middle, Last)_____________________________________________
Your Date of Birth_____________________ Your Social Security Number (optional):______________
Are you a/an:
Adult Adopted Person (21 or older)
Birth Mother
Birth Father
Adoptive Parent(s)
Birth Sibling adopted
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Adult descendant of a deceased Adopted
Person
Spouse of a deceased Adopted Person
Adult relative of deceased Birth Parent
Other eligible relative
_______________
Street Address
______________________________________
City, State, Zip Code
Email address:
______________________________________
Home phone number:
____________________________
Cell phone number:
_____________________________
Work phone number:
____________________________
Best place to reach me (circle one): home
cell work
Adopted Person’s date of birth:
___________________
Name(s) of Adoptive Parents at the time of the
adoption:
______________________________________
OR
Birth Mother’s date of birth:
______________________
Name(s) of Birth Parents at the time of the
adoption:
______________________________________
______________________________________
Adopted Person’s Name at time of adoption or birth
___________________________________________
Special mailing instructions (i.e. plain envelope for privacy, or a trusted friend or relative who will be your contact person):
_______________________________________________________________________________
_______________________________________________________________________________
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2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Other Relevant Information (if adopted person or birth parent is deceased, please provide information, i.e. date of death, cause of death, etc.):
_________________________________________________________________________ ______
_______________________________________________________________________________
Signature: ___________________________________________
Date: _____________________________
Parental Permission (if applicable):
I/We are aware that an adopted person under 21 years of age must have the written consent of the adoptive
parent(s) in order to receive non-identifying information. I/We do hereby give my/our permission for
__________________________, who is 18-20 years of age, to receive non-identifying information. Attached is a
copy of my/our photo ID(s).
Signature:
Date:
I would like to receive
General Cradle Newsletter □ Yes □ No
Cradle e-newsletter □ Yes □ No
12/11 x:/Materials/Post Adoption/Forms/Client Identification.doc

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
What Every Client Should Know
Dear Client,
Thank you for choosing The Cradle. Regardless of the circumstances that have brought you to our
organization, we will endeavor to make your experience with us as positive, satisfying and fulfilling as possible.
We view our relationship with you as a true partnership. To that end, we want to take this opportunity to tell
you what you can expect from the staff of The Cradle and we want to explain what we expect from you.
We will endeavor to treat you with consideration and respect for your personal dignity and
privacy. Information obtained during the course of receiving service from The Cradle is
privileged and will not be released without your written consent, except as required by
applicable laws. We hope you will extend the same consideration to others if, while receiving
services, you are in contact with or learn information about other clients of The Cradle.
We embrace the importance of each client’s self-determination. We hope that you will be
an active participant in our program and take full advantage of the many service opportunities
that exist. We regard each client as a unique individual and we respect your desire to make
decisions that are best for you based on the educational and counseling services you receive. It
is important that you also understand that decisions you make may have implications for other
clients. The nature of our mission is such that we must consider our clients equally. However,
our first obligation is to promote and protect the interest of children.
Should you wish to access your record, please give the staff member with whom you are
working reasonable notice so that we can make the appropriate arrangements. (The Cradle’s
usual business hours are from 8:30 am to 5:00 pm, Monday through Friday. Individual needs
may be discussed with a counselor and arrangements may be made for after-hours
appointments.)
You should expect complete honesty from every staff member with whom you have contact.
Similarly, it is imperative that you be completely honest with us. We believe that open
communication is essential. In the event we feel that The Cradle’s services are not appropriate
for you, we will give you an explanation. If you decide to withdraw from our services, it would
be helpful for us to understand your reasons in order for us to continually improve.
If you are receiving services for which The Cradle charges fees, we will keep you informed of
these fees.
The Cradle abides by local, state and federal laws regarding discrimination practices.
As much as we appreciate receiving positive feedback, we realize that there may be points in the process
when you are not satisfied. Your first step is to be open and direct with your social worker. We understand
that this can be difficult. Sometimes clients feel that they will be penalized for raising concerns or
complaints. In fact, we value your feedback and we pledge to use it constructively.

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
When you have a concern you should share it with your social worker. If you are more
comfortable sharing your concern directly with the supervisor you may certainly do so.
Please know, however, that it is our practice at The Cradle to keep all lines of
communication open. Thus, you should expect that the supervisor will share your concern
with your social worker. Open discussions can often address the concern and resolve the
issue satisfactorily. If, however, you are not satisfied with the outcome after these
discussions, you may initiate a formal Problem Resolution Process.
When beginning the formal Problem Resolution Process, take the time to describe, in
writing, the nature of your concern and forward it to the Executive Director of Adoption
Services (“Executive Director”). The Executive Director will initiate an investigation of
your complaint within 2 business days upon receipt of the complaint. The Executive
Director will share your complaint with your social worker and his/her supervisor and
discuss your concerns and determine whether correctable action is indicated. You may be
asked to meet with your social worker, his/her supervisor, and Executive Director.
We will endeavor to expedite this process but the actual amount of time it takes depends on
a variety of factors including the availability of all the staff members involved, but in no
event will it be longer than 10 business days unless extenuating circumstances exist which
require additional time for resolution. Should this occur, you will be notified at least by day
ten of the need to continue the investigation.
As required by law, the Agency will report the outcome of its complaint investigation in
writing to the Department of Children and Family Services (DCFS) regional licensing office
or the DCFS Licensing Representative within 10 business days after complaints are
received unless extenuating circumstances exist which require additional time for
resolution. DCFS will also receive an update at day ten should additional time be required.
The Executive Director will be responsible for reporting on the nature of the complaint and
resolution at the Agency’s next Board of Directors meeting.
At no time will the Agency retaliate against complainants.
Thank you, again, for choosing The Cradle.
I/We have read, understand, and agree to this explanation of Expectations and PROBLEM resolution.
Signature: _______________________________________________
Printed Name: ____________________________________________ Date: ___________
Signature: _______________________________________________
Printed Name: ____________________________________________ Date: ___________

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
The Cradle
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your client file may contain personal information about your health and/or the health of your child(ren). This
information may identify you and relates to your past, present or future physical or mental health condition and
related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy
Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code
of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties
and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy
Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any
new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will
provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website,
sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Services. Your PHI may be used and disclosed by those who are involved in your care for the purpose of
providing, coordinating, or managing your services. This includes consultation with clinical supervisors or
other team members. We may disclose PHI to any other consultant only with your authorization.
For Business Operations. We may use or disclose, as needed, your PHI in order to support our business
activities including, but not limited to, quality assessment activities, employee review activities, licensing, and
conducting or arranging for other business activities. For example, we may share your PHI with third parties
that perform various business activities (e.g., Council on Accreditation or other regulatory or licensing bodies)
provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we
must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of
investigating or determining our compliance with the requirements of the Privacy Rule, if so required.
Without Authorization. Applicable law and ethical standards permit us to disclose information about
you without your authorization only in a limited number of other situations. Examples of some of the
types of uses and disclosures that may be made without your authorization are those that are:
Based largely on text provided by the
NATIONAL ASSOCIATION OF SOCIAL WORKERS
DOCUMENT D2
© Popovits & Robinson, P.C. Page 1 of 2
4-2003
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2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government
agency audits or investigations (such as the social work licensing board or the health department)
Required by Court Order
Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the
public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person
or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Verbal Permission
We may use or disclose your information to family members that are directly involved in your receipt of
services with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only
with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights,
please submit your request in writing to our Privacy Officer, Merrilee Hepler, Vice President
Human Resources & Administration at The Cradle, 2049 Ridge Ave., Evanston, IL, 60201:
Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional
circumstances or with documents released to us, to inspect and copy PHI that may be used to make
decisions about service provided (please refer to the Client’s Rights document for further details).
Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may
ask us to amend the information although we are not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain of
the disclosures that we make of your PHI. We may charge you a reasonable fee if you request
more than one accounting in any 12-month period.
Right to Request Restrictions. You have the right to request a restriction or limitation on the
use or disclosure of your PHI for services, payment, or business operations. We are not
required to agree to your request.
Right to Request Confidential Communication. You have the right to request that we
communicate with you about PHI matters.
Right to a Copy of this Notice. You have the right to a copy of this notice.
COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with
our Privacy Officer at The Cradle or with the Secretary of Health and Human Services at 200
Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate
against you for filing a complaint.
The effective date of this Notice is April 14, 2003.
Based largely on text provided by the
NATIONAL ASSOCIATION OF SOCIAL WORKERS
DOCUMENT D2
© Popovits & Robinson, P.C. Page 2 of 2
4-2003
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Notice of Privacy Practices
Receipt and Acknowledgment of Notice
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Client Name:_____________________________________________
DOB: ___________________________________________________
SSN (Optional):___________________________________________
I hereby acknowledge that I have received and have been given an opportunity to
read a copy of The Cradle’s Notice of Privacy Practices. I understand that if I have
any questions regarding the Notice or my privacy rights, I can contact Merrilee
Hepler, Vice President, Human Resources & Administration and Risk Management
Officer, located at The Cradle, 2049 Ridge Ave., Evanston, IL, 60201, 847-733-3223.
_________________________________________________________________
Signature of Client
Date
_________________________________________________________________
Signature of Parent, Guardian or Personal Representative Date
__________________________________________________________________
• If you are signing as a personal representative of an individual, please describe your
legal authority to act for this individual (For example, power of attorney).
₃ Client Refuses to Acknowledge Receipt:
_________________________________________________________________
Signature of Staff Member
Date
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Information Exchange Authorization
I/We, _________________________________________, state that I/we am/are the person/people who
completed the Client Identification; that I am ______ years of age; that I hereby authorize The Cradle to
give the following person(s): (check as applicable)
Adult adopted person (21 or older) Birthmother Birthfather Adoptive Parent(s) Birth
Sibling adopted Adult descendant of a deceased Adopted Person Spouse of a deceased Adopted
Person
Adult relative of deceased Birth Parent all eligible relatives
the following information:
(please check the information authorized for exchange)
Release my name and contact information on this document, and/or the most recent contact
information I provided The Cradle.
Contact me first before releasing my name and contact information.
My contact information is as follows:
My Name or Name of Person Through Whom I May Be Contacted
Street Address
Home Phone
___________________
Cell Phone
City, State, Zip Code
E-mail
Signature
Date
Please be sure to keep The Cradle updated about your contact information.
State of ______________________________ County of ________________________________
I, a Notary Public, in and for this county, in the state aforesaid, do hereby certify that
is personally known to me to
be the same person whose name is signed to the foregoing Information Exchange Authorization, appeared
before me in person and acknowledged that she/he signed such certificate as her/his free and voluntary act and
that the statements in such authorization are true.
Given under my hand and notarial seal this _____ day of ___________________, ________.
(Seal)
______________________________________________
Signature

__________________________________________________________________________________
Writing “Your First Letter”
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
When a birth relative is located, the question is often, "what do we do now?" While many
people want to meet right away, our experience has taught us that often the best reunions are
those that proceed more slowly, allowing the relationship to grow and develop over time.
Taking things slowly gives each person an opportunity to get to know one another as well as
deal with the myriad of often conflicting emotions that may arise.
To begin this process, we ask that you write a letter to your birth relative that does not contain
any identifying information. This letter is an opportunity for you to introduce yourself. You
may wish to include a brief summary of major events in your life, as well as a statement about
how your adoption experience has affected your life. It will also be important to include what
you are hoping for from this contact. Many people, when first located, feel more comfortable
beginning contact with letters and photos exchanged confidentially and anonymously through
The Cradle. You may wish to express your willingness to begin contact in this manner.
We have found that in these letters, using terminology such as "birth parent," "birth son," and
"birth daughter" can be helpful. Although you may wish to do so, please do not include your
last name, address, phone number, or email in this letter. It is best to wait until both you and
your birth relative are comfortable before releasing this information.
For photographs, you may wish to include several of yourself from childhood through the
present. In addition, if you have children you are parenting or have parented, you may wish to
include photos of them. If you do not want to part with certain photos (for example of yourself
as a child), you could send color photocopies. Please do not select photographs of yourself in
which you are wearing sunglasses.
If we are able to locate your birth relative, we will make this letter available to him or her. If
we are not able to locate your birth relative, or if your birth relative is not open to receiving
your letter, it will remain in our files. Should we hear from your birth relative in the future,
this letter will then be available to him or her.
While this letter may be difficult to write, please remember that it is your birth relative’s first
introduction to you as a person. Keep in mind that you cannot say everything in one letter, and
that too much information can be overwhelming for the recipient. Hopefully, this will be the
first of many contacts. If you would like us to review a draft of your letter, please feel free to
send, email, or fax it to us. Remember that it does not have to be perfect, just sincere. The
most important thing of all is just to start writing!

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Personal History & Biography Questionnaire
Adoptive Parent
When we are working on your behalf making an outreach or searching for birth relatives, it is helpful to have some
information about you and your child. Your answers to the following questions will assist us in serving you
throughout the process. Additionally, we will be better able to represent you and your child should contact be made
with a birth relative. The non-identifying information you provide can, by law, be shared with your child’s birth
relative. Please feel free to use additional pages as needed.
Name:
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
1. What is your marital status?
2. What are the ages and genders of your children?
3. What are some of your child’s hobbies, skills, and interests?
4. What is your child’s educational background?
5. How would you describe your child’s development?
6. What is your relationship with your child like now?
7. What are the main motivating factors in your decision to begin the search process at this time?
8. Does your child know about this choice?

9. What are his/her thoughts and feelings about your decision?
10. Do you know anyone who has attempted a search of this nature? Please describe.
11. How have you prepared yourself and your child for the search process?
12. What is your/your child’s primary means of emotional support? (answers could include but are
not limited to: religion, family, counseling/therapy, and support groups)
13. What do you imagine as the best outcome of your search efforts?
14. What do you imagine as the most difficult outcome of your search efforts?
15. Are there any specific medical conditions that you are concerned may be in your child’s birth
family history?
16. If you or your child could say one thing to your child’s birth parent, what would it be?
17. Is there any additional information we should know about you or your child in order to assist
you throughout this process?
Signature
Date