Adoptive Parents Forms - The Cradle

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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: ___________________________________ 11/11 x:/Materials/Post Adoption/Forms/Fee Schedule.doc
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): _______________________________________________________________________________ _______________________________________________________________________________ 12/11 x:/Materials/Post Adoption/Forms/Client Identification.doc
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Page 9: Notice of Privacy Practices Receipt
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Adoptive Parents Forms - The Cradle

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