Adult Adopted Person Forms - The Cradle

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Description of Services
Non-Identifying Information
The amount of information in The Cradle’s records varies according to the length of time we worked with the birth
parent(s) and the year in which the adoption was planned. Cradle adult adopted people may request nonidentifying
information at age 21 or older, or with parental permission between the ages of 18-20. Cradle adoptive
parents may request non-identifying information at any time.
Background History Report
The Cradle can provide all of the available non-identifying information of birth relatives as recorded. This
information usually includes age, physical description, religion, national descent, education level, occupation,
and marital status. When available we can also provide a description of the birth parents’ interests, their
relationship with each other, and the circumstances surrounding the decision to plan adoption. We will also let
you know if we have had any contact with anyone from your birth family since the time of the adoption.
Due to growing awareness about genetic medical conditions, many people have questions about their medical
history. We are able to provide all the known medical information in our records about birth family members.
This information often includes any known diseases within the birth family, a description of the pregnancy, facts
about the labor and delivery process, records of time spent in the Cradle Nursery, and any medical developments
of which we have been notified.
Brief Update Report
Often we hear from people who received their non-identifying information years ago, and now they are
interested in knowing if there is any additional information in the record. If you have received non-identifying
information in the past, you can request the Brief Update Report. This offers an additional opportunity for a
review of your record. We will also let you know if we have had any contact with anyone from your birth family
since the time of the adoption.
File Check
We receive many calls from people asking if we have had any contact with the adopted person or anyone from
their birth family since the time of the adoption, as well as people asking for suggestions on whether they should
become a part of The Cradle’s Mutual Consent Registry, or move forward with a Search. With the File Check,
we will review the records and let you know if we have had any contact with your birth relative(s) since the time
of the adoption or if there is a Registry on file for your birth relative.
Birth Parent Report
For Birth Parents, The Cradle can provide basic non-identifying information about your birth child’s adoptive
family at the time of the adoption. This report includes information about the birth of the baby and his or her
early development. We will also let you know if we have had any subsequent contact from your birth child or
from the adoptive family since the time of the adoption.
Mutual Consent Registry
Many things have changed in adoptions over the years, and Illinois now allows contact between birth parents and
adult adopted people as long as both have given their consent.
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The Cradle’s Mutual Consent Registry
Many people choose to sign The Cradle’s Mutual Consent Registry. The registry, which was created in 1985,
allows people to let us know that they are open to having contact with a birth relative. Cradle adopted people
may register at age 21. Cradle adoptive parents of a child under age 21 may register on behalf of their child.
Cradle birth parents may register at any time following the adoption. Under certain conditions, relatives of birth
parents and descendants of adopted people may also register. Once the forms are submitted for The Cradle’s
Registry, they remain on record indefinitely. If there is a match, at the time of registering or in the future, The
Cradle will contact each person and assist in exchanging information based on preauthorization from each
individual involved. If direct contact is not desired, The Cradle can facilitate an exchange of letters, photos,
information, telephone calls, or a meeting.
PLEASE NOTE: It is important when participating in the registry to keep The Cradle updated on any
changes to your name, phone number, email or mailing address.
The Illinois Adoption Registry and Medical Information Exchange
The Illinois Adoption Registry was created as a means for those involved in an adoption that took place in
Illinois to contact biological relatives. The Cradle Registry is not connected to The Illinois Adoption Registry.
The law requires that a person requesting a Search must be registered with the Illinois Adoption Registry before
a private agency like The Cradle may conduct any Search and Outreach for a biological relative. In order for
The Cradle to proceed with a request for a Search, we need a copy of the confirmation letter you received from
the Illinois Adoption Registry verifying your registration. Forms for the Illinois Adoption Registry can be
obtained through the website, www.idph.state.il.us or by calling 877-323-5299 (toll-free) or (217) 557-5159.
Reaching Out
In some cases we are not able to make a match through the Registry. When that is the case, many of our clients
choose to move ahead with a Search for their birth relative. In conducting a Search, The Cradle uses information
given at the time of the adoption and any information obtained thereafter. A variety of Search techniques are used
depending on the information available. Searches through The Cradle are conducted in an ethical and respectful
manner, and the confidentiality of all parties is maintained. It is important to consider the many possible outcomes
when requesting a search. Reaching Out services are for Cradle families only.
Basic Search
All searches begin with a Basic Search. A Basic Search utilizes the information available in the record and
Internet search engines, to try to locate a current address for your birth relative. If a possible address is located,
an outreach letter is sent to your birth relative. When a current address is not located through a Basic Search,
people often choose to upgrade to an Extended Search.
Extended Search
An Extended Search goes beyond the information available in the record and the use of the Internet. Often this
includes extensive research of demographic, historical, archival, and genealogical records, both public and
private. Once a possible address is located, an outreach letter is sent to your birth relative.
The time it takes to search for a birth relative can vary from a few weeks to more than a year. Although we are
usually able to locate the person we are seeking, we cannot guarantee that a Search will be successful. The
majority of adopted people and birth parents we locate are open to contact; some are not. If you request a
Search, be prepared for the possibility that your birth parent or child may choose not to have contact.
Additionally, if we discover your birth relative is deceased, we then look for the closest next of kin. If your birth
relative is open to contact, The Cradle can act as intermediary exchanging letters and photos until both parties
feel comfortable with direct contact. The Search fee, regardless of the outcome, is non-refundable.
Counseling/consultation as needed is included in the Search fee to help with thoughts, feelings, and emotions that
may result from this process.
2
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Reconnection
From time to time, birth relatives who were in contact through an open or semi-open adoption, or a successful
Search facilitated by The Cradle, lose touch. One avenue of trying to reconnect is for The Cradle to attempt to
locate a current address through the use of Internet search engines and then send an outreach letter to your birth
relative, or your child’s birth relative. To request this service you must be a part of The Cradle’s Mutual Consent
Registry. Please call us for additional information and to see if this service applicable for you.
Life-Long Support
Research and our experience have consistently shown that adoption affects people in many ways throughout their
life spans. For all members of the adoption circle, the experience of adoption weaves through normal growth and
development.
Counseling/Consultation
The Cradle offers both one-time consultations as well as ongoing counseling services to all members of the
adoption circle. Our experienced adoption counselor can provide individual, couple, and family counseling. We
also have positive working relationships with many therapists in the greater Chicago area who have expertise in
adoption related issues, and we can provide you with additional counseling referrals. Additionally, The Cradle is
available for mediation between parties in an adoption. Counseling/Consultation and mediation is open to any
family, whether they adopted through The Cradle or not.
Training & In-Service
For agencies, organizations, educators, and professionals, including child welfare and adoption workers and
others who interact with families touched by adoption, in-service programs are available. For families, the pre
and post adoption training we offer addresses the issues required by State and Federal regulations in a lively and
useful format. Training is open to any family, whether they adopted through The Cradle or not. Information is
available on The Cradle website. http://www.cradle.org/traininged_home.html
Other Support
The Cradle recognizes support systems are evolving, as social networking becomes more common and
acceptable as forms of communication and support. Postings can be found on Connections, The Cradle’s online
adoption community forum http://www.cradle.org/forum/ and The Cradle’s Facebook Page
http://www.facebook.com/TheCradleAdoptionServices .
We also offer a series of workshops to support families connected through adoption. These are open to any
family, whether they adopted through The Cradle or not. The workshop schedule can be found on The Cradle
website. http://www.cradle.org/post_workshops.html
Adoption Learning Partners is a web-based educational adoption resource for professionals, parents, adopted
individuals, and the families that love them. http://www.adoptionlearningpartners.org/index.cfm
To inquire about our counseling/consultation services, our training & in-service programs, or if you do not find
what you are looking for listed here, please call 847-475-5800 and ask to speak with a member of our Post
Adoption department to describe your needs, or email us at cradle@cradle.org or through our website.
http://www.cradle.org/forms/emform.php?form=18
Please see the “Checklist” in order to insure you have included all forms necessary to request the service(s) you have selected.
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If you are requesting:
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Checklist for Post
Adoption Services
File Check
You will need to return
Client Information
Fee Schedule (with payment)
Copy of Valid driver’s license,
state ID, or passport
Background History Report
Brief Update Report
Birth Parent Report
You will need to return
Client Information
Fee Schedule (with payment)
Copy of Valid driver’s license,
state ID, or passport
Dear Client Letter (signed)
Privacy Acknowledgment (signed)
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth parents, optional for others)
Mutual Consent Registry
You will need to return
Client Information
Fee Schedule (with payment if applicable)
Copy of Valid driver’s license,
state ID, or passport
“Your first letter” (optional)
Registration Identification
Information Exchange Authorization
(Notarized)
Dear Client Letter (signed)
Privacy Acknowledgment (signed)
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth parents, optional for others)
Search
You will need to return
Please see the “Description of Services” if you have any questions about
these services.
* Illinois Adoption Registry forms enclosed in packet
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.
Client Information
Fee Schedule (with payment)
Copy of Valid driver’s license,
state ID, or passport
Registration Identification
Information Exchange Authorization
(Notarized)
Personal History & Biography
Questionnaire
“Your First Letter”
Dear Client Letter (signed)
Privacy Acknowledgment (signed)
*Copy of Illinois Adoption Registry
Confirmation Letter
Copy of Illinois Adoption Registry
Medical Questionnaire (required for
birth parents, optional for others)
(before requesting a Search, registration with
the state of Illinois is required)
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Fee Schedule
Post Adoption Services
Your Full Name (please print): ___________________________________________________ Date: ________________
Requested Service(s)
Non-Identifying Information
Registry
Background History Report (DOB 1923-1940) $50
Fees
Background History Report (DOB 1941-present) $125
Brief Update (if you have previously received background information) $50
File Check $25
Birth Parent Report (for Birth Parents only) $0
Registry OR $40
Registry with Illinois Adoption Registry Medical Questionnaire $0
Reaching Out
Basic Search $225
Extended Search (if Basic Search is unsuccessful) $300
Reconnection $50
2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
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
Total Fees: __________
Contribution: __________
Payment Method Total Payment: __________
Check made out to The Cradle enclosed
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 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 Information
Your Name (First, Middle, Last) _______________________________________________________________________
Are you a/an:
Adult Adopted Person
Birth Father
Adoptive Parent
Birth Sibling Adopted
Adult descendant of Adopted Person
Surviving relative of deceased Birth Parent
Birth Mother
Other
Name(s) of Adoptive Parents at the time of the adoption:
Adopted Person’s date of birth: ___________________
Birth Mother’s date of birth: ______________________
Your social security number: _____________________
OR
Name(s) of Birth Parents at the time of the adoption:
_____________________________________________
Your home phone number: _______________________
Your work phone number: _______________________
Your cell phone number: ________________________
Your Email address: ___________________________
Your Home Address:
______________________________________________________________________________________________
______________________________________________________________________________________________
Special mailing instructions (i.e. plain envelope for privacy, or a trusted friend or relative who will be your contact person):
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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:
Signature:
Date:
Date:
Would you like to receive:
Post Adoption Workshop/Support Group Notices (Chicagoland Only)
Yes
No
General Cradle Newsletter
Yes
No
Cradle Events
Yes
No
09/09 x:/Materials/Post Adoption/Forms/Client Information.doc

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Registration Identification
I/We,
, state that I/we am an
(check one) adopted person 21 years of age or older OR , that I/we am the birthmother birthfather
birth sibling adopted adoptive parent(s) adult descendent (of a deceased adopted person)
surviving adult relative of a deceased birth parent surviving spouse (of a deceased adopted person)
of a child who was adopted through The Cradle, Evanston, IL, at the approximate age of , and that the
following information is true to the best of my knowledge.
Please print all known information:
Adopted Person: (name at time of adoption or birth)
First Middle Last
Date of Birth Sex City and State of Birth
Adoptive Parent 1:
First Middle Last
Adoptive Parent 2:
First Middle Last
Birth Mother: (name at time of adoption)
First Middle Last
Birth Father: (name at time of adoption)
First Middle Last
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
________________________________________________________
Signature (Adoptive Parent 2 if applicable)
__________________
Date
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2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Information Exchange Authorization
I/We, _________________________________________, state that I/we am the person who completed the Registration Identification;
that I am ______ years of age; that I hereby authorize The Cradle to give the following person(s): (check as applicable)
adopted person birthmother birthfather birth sibling adopted adoptive parent(s) other birth relative(s)
adult child of a deceased adopted person surviving spouse of a deceased adopted person all eligible relatives
the following information:
(please check the information authorized for exchange)
Contact me first before releasing identifying information.
Only my name and last known address can be released.
A copy of the completed medical questionnaire can be released.
I am fully aware that I can only be supplied with any information about the individual(s) who has duly executed an Information
Exchange Authorization for the information which authorization has not been revoked.
My contact information is as follows:
My Name or Name of Person through Whom I May Be Contacted
Phone
Street Address
City, State, Zip Code
E-mail
Signature
Date
*adopted person must be 21 years of age or older to Register.
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
09/09 x:/Materials/Post Adoption/Forms/infoex.doc

Our mission is to benefit children…by providing education, guidance
and lifelong support on parenting choices. Our commitment is to serve as a partner
in creating and sustaining nurturing families.
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.
2007

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.
• 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: ___________
2007

Our mission is to benefit children…by providing education, guidance
and lifelong support on parenting choices. Our commitment is to serve as a partner
in creating and sustaining nurturing families.
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.
2007

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.
• 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: ___________
2007

Personal History & Biography Questionnaire
Adopted Person
When we are working on your behalf making an outreach or searching for birth relatives, it is helpful to have some
information about you. Your answers to the following questions will assist us in serving you throughout the process.
Additionally, we will be better able to represent you should contact be made with a birth relative. The nonidentifying
information you provide can, by law, be shared with your 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. Do you have any children? If so, what ages, and genders?
3. What are some of your hobbies, skills, and interests?
4. What is your educational background?
5. Briefly describe your employment history.
6. How would you describe your childhood?
7. What is your relationship with your adoptive family like now?
8. Does your adoptive family know about your decision to search?
(Continued on Back)
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9. If so, what are their thoughts and feelings about your decision?
10. What are the main motivating factors in your decision to begin the search process at this time?
11. Do you know anyone who has attempted a search of this nature? Please describe.
12. How have you prepared for the search process?
13. What is your primary means of emotional support? (answers could include but are not limited to: religion, family,
counseling/therapy, and support groups)
14. What do you imagine as the best outcome of your search efforts?
15. What do you imagine as the most difficult outcome of your search efforts?
16. Are there any specific medical conditions that you are concerned may be in your birth family history?
17. If you could say one thing to your birth relative what would it be?
18. Is there any additional information we should know about you in order to assist you throughout this process?
Signature
Date
09/09 x:/Materials/Post Adoption/Forms/questionnaire_ad.doc

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 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!
09/09 x:/Materials/Post Adoption/Forms/Your First Letter.doc

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:
• 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.
Based largely on text provided by the
NATIONAL ASSOCIATION OF SOCIAL WORKERS
DOCUMENT D2
© Popovits & Robinson, P.C. Page 1 of 2
4-2003
X:\Materials\HIPAA Client Forms\HIPAA Client Notice of Privacy Practices.doc

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
X:\Materials\HIPAA Client Forms\HIPAA Client Notice of Privacy Practices.doc

2049 Ridge Avenue, Evanston, Illinois 60201. 847-475-5800
Reading Suggestions
Talking With Children About Adoption
Being Adopted: The Lifelong Search for Self
David M. Brodzinsky, Marshall D. Schechter & Robin
Marantz Henig
Why Didn’t She Keep Me?
Barbara Burlingham-Brown
Talking to Your Child about Adoption
Patricia Martinez Dorner
Making Sense of Adoption: A Parent’s Guide
Lois Ruskai Melina
Dear Birthmother
Kathleen Silber, Phylis Speedlin
Talking with Young Children about Adoption
Mary Watkins, Susan Fisher
Children’s Books About Adoption
Together Forever: An Adoption Story Coloring Book
Sara L. Barris
The Mulberry Bird: Story of an Adoption
Anne Braff Brodzinsky
How Was I Adopted: Samantha’s Story
Joanna Cole
Tell Me Again about the Night I Was Born
Jamie Lee Curtis
Susan and Gordon Adopt a Baby: Based on the Sesame
Street Television Script
Judy Freudberg, Tony Geiss
A Mother for Choco
Keoko Kasza
How It Feels to Be Adopted
Jill Krementz
Beginnings: How Families Come to Be
Virginia Kroll
Pugnose Has Two Special Families
Karis Kruzel
Twice-Upon-A-Time: Born and Adopted
Eleanora Patterson
Families Are Different
Nina Pellegrini
Lucy’s Feet
Stephanie Stein
Open Adoption
How to Open an Adoption: A Guide for Parents and Birth
Parents of Minors
Patricia Martinez Dorner
The Spirit of Open Adoption
James L. Gritter
Openness in Adoption: Exploring Family Connections
Harold Grotevant, Ruth McRoy
The Open Adoption Experience
Lois Ruskai Melina, Sharon Kaplan Roszia
A Letter to Adoptive Parents on Open Adoption
Randolph W. Severson
Children of Open Adoption
Kathleen Silber, Patricia Martinez Dorner
The Open Adoption Book
Bruce M. Rappaport
Understanding Adopted Persons
Being Adopted: The Life Long Search for Self
David M. Brodzinsky, Marshall D. Schechter & Robin
Marantz Henig
Journey of the Adopted Self: A Quest for Wholeness
Betty Jean Lifton
(Continued on Back)

Children’s Adjustment to Adoption: Developmental and
Clinical Issues
David M. Brodzinsky, Anne B. Brodzinsky & Daniel W.
Smith
Primal Wound: Understanding the Adopted Child
Nancy Newton Verrier
Twice Born: Memoirs of an Adopted Daughter
Betty Jean Lifton
Understanding Birth Parents
The Girls Who Went Away – The Hidden History of
Women Who Surrendered Children for Adoption in the
Decades Before Roe v. Wade
Ann Fessler
Birth Mothers: Women Tell Their Stories
Merry Jones
Out of the Shadows: Birthfathers’ Stories
Mary Martin Mason
Waiting to Forget
Margaret Moorman
Saying Goodbye to a Baby: Volume I – The Birth
Parent’s Guide to Grief and Loss in Adoption
Patricia Roles
The Other Mother: A Woman’s Love for the Child She
Gave up for Adoption
Carol Schaefer
Dear Birthfather
Randolph W. Severson
Dear Birthmother
Kathleen Silber, Phylis Speedlin
Giving Away Simone: A Memoir
Jan L. Waldron
without a map
Meredith Hall
Understanding Adoptive Parents
Wanting a Child
Jill Bialosky, Helen Schulman
Courageous Blessing: Adoptive Parents and the Search
Carol L. Demuth
The Limits of Hope: An Adoptive Mother’s Story
Ann Kimble Loux
Secret Thoughts of an Adoptive Mother
Jana Wolff
Adopting after Infertility
Patricia Irwin Johnston
Reunions
Birth Bond: Reunions between Birthparents and Adoptees
– What Happens After…
Judith Gediman, Linda P. Brown
A Man and His Mother: An Adopted Son’s Search
Tim Green
The Mistress’s Daughter
A.M. Homes
Lost and Found: The Adoption Experience
Betty Jean Lifton
Ithaka: A Daughter’s Memoir of Being Found
Sarah Saffian
A Wealth of Family: An Adopted Son’s
Int’l Quest for Heritage, Reunion and Enrichment
Thomas Brooks
03/08 2
x:/Materials/Post Adoption/Forms/Reading Suggestions.doc

GENERAL INSTRUCTIONS FOR COMPLETING
ILLINOIS ADOPTION REGISTRY-MEDICAL INFORMATION EXCHANGE (IARMIE) FORMS
Type or print (in ink) all known information asked for on the forms. If you do not know the information, please leave that item
blank.
All registrations must contain the following basic forms/items:
1. Your specific Registration Identification form (Adopted Person, Birth Parent, etc.)
2. Illinois Adoption Registry Application form
3. Your registration MUST INCLUDE a photocopy of a government issued photo ID. Acceptable IDs are:
driver’s license with photo, government issued photo ID cards or passport.
You must choose upon completion of your basic registration forms one of these options: Select the one that best defines
what you wish to accomplish with your registration and submit the required items/forms.
A. If you wish to exchange medical information, with or without exchanging identifying information, you must
include the following forms in addition to your basic registration forms:
4. A properly completed Information Exchange Authorization form **See note
5. A completed medical information questionnaire form
B. If you wish to exchange identifying information but NOT medical information you must include these forms/items
in addition to your basic registration forms:
4. A properly completed Information Exchange Authorization form **See note
5. The required registration fee of $40 - made payable to the Illinois Department of Public Health. NOTE: this fee
is waived for persons agreeing to exchange the medical information questionnaire, which contains NO
identifying information.
C. If you wish to deny contact of any kind, you must include these forms/items in addition to your basic registration
forms:
4. A properly completed Denial of Information Exchange form **See note
5. The required registration fee of $40 - made payable to the Illinois Department of Public Health. NOTE: this fee
is waived for persons agreeing to exchange at least the medical information questionnaire, which contains NO
identifying information.
**NOTE: The applicant=s signature must be notarized on the “Information Exchange Authorization@ or the ADenial of
Information Exchange@ forms. If the form does not contain your signature and that of the notary, as well as the notary’s
seal, you will be sent another form to properly complete before being placed in the IARMIE.
In addition to the completed registration, you may submit the following optional items:
Optional written statements and optional photographs - Sign Section B and C on the Illinois Application form to authorize the
release of the documents. These will be released to the person(s) you wish to exchange information with as indicated on your
Information Exchange Authorization. Photographs are to be of the registrant alone and are to be no larger than 82@ X 11".
Statements may not contain any specific names, dates or places.
Effective January 1, 2004:
Adopted Persons, Adoptive Parents and Legal Guardians of Adopted Persons have the option to request non-identifying
information that is contained within the certifiable portion of the original birth record being released to them. You will need to sign
and date Section D of the Illinois Adoption Registry Application form to receive this information.
Birth Parents have the option to request confirmation of the date and place of birth of the child from the original birth record.
You will need to sign and date Section E of the Illinois Adoption Registry Application form to receive this information.
If you have questions or would like help or guidance in completing the forms, please feel free to contact the Illinois Adoption
Registry. If you live in Illinois you may call the registry toll free at 877 - 323 - 5299. If you live outside of Illinois, the telephone
number to call is 217 - 557 - 5159. The Illinois Adoption Registry does have voice mail and those who leave a name, telephone
number and the best time reach them will receive a return call.
Mail the completed registration, which is the basic registration forms and the forms from option A, B or C (whichever you
chose) to: Illinois Adoption Registry and Medical Information Exchange, Illinois Department of Public Health, Division of Vital
Records, 605 W. Jefferson St., Springfield, IL 62702-5097

This application is
Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY
AND MEDICAL INFORMATION EXCHANGE APPLICATION
❏ a new registration ❏ an update to a prior registration (please note any updates must be accompanied by ID).
I am registering/registered as (check one) ❏ an adult adopted or surrendered person; ❏ a birth parent; ❏ adoptive parent or
legal guardian of an adopted or surrendered person; ❏ surviving relative of a deceased birth parent; ❏ surviving relative of a
deceased adopted or surrendered person as stated on the registration identification.
Section A. REGISTRANT INFORMATION
Name: _________________________________________________________________________
(first) (middle) (maiden if applicable) (last)
Today’s date: _______________
Mailing address: _____________________________________________________________________________________________
(street) (city) (state) (ZIP code)
Sex: __________ SSN______-_____-___________ Phone: ( ____ ) _________________
(male or female)
(OPTIONAL)
Section B. COMPLETE WHEN OPTIONAL PHOTOGRAPH(S) ARE BEING FILED
The enclosed photograph(s) is (are) to be released to the person(s) specified on my Information Exchange Authorization form. The photograph(s)
does (do) not include identifying information pertaining to any person other than myself, and do not include anyone else.
(NOTE: Photograph(s) are to be no larger than 8 fi" x 11")
__________________________________________________
Applicant Signature/Date
Section C. COMPLETE WHEN OPTIONAL WRITTEN STATEMENT IS BEING FILED
An optional written statement (on the prescribed form) is enclosed and is to be released to the person(s) specified on my Information
Exchange Authorization form. This statement does not include any identifying information pertaining to any person other than myself
and does not include any specific names, dates or places.
__________________________________________________
Applicant Signature/Date
Section D. SIGN WHEN REQUESTING NON-IDENTIFYING INFORMATION BE RELEASED
I, the undersigned, request that any non-identifying information, as detailed in 750 ILCS 50/18.4(a)(c), be released to me. I understand
that non-identifying information can only be provided to an adopted person, adoptive parent or legal guardian who is a registrant
of the Illinois Adoption Registry.
Adopted/Surrendered name____________________________________
Date of birth ______________________
_____________________________________________
Applicant Signature/Date
Section E. SIGN WHEN REQUESTING ACTUAL DATE AND PLACE OF BIRTH BE RELEASED TO BIRTH PARENT
I, the undersigned, request that I be provided with the actual date and place of birth of the child I placed for adoption per 750 ILCS
50/18.4(d).
__________________________________________________
Applicant Signature/Date
See other side for a list of required documentation.
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR161 (rev. 08/2004) Printed by Authority of the State of Illinois P.O. #146104 3M 2/06 IL482-1014

REQUIRED DOCUMENTATION
Adopted/Surrendered Person or Adoptive Parent or Legal Guardian of an adopted/surrendered person
❏ Appropriate Registration Identification form
❏ Adoption Registry Application form
❏ Photocopy of photo identification
❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form
With one of the following:
With $40.00 registration fee made payable to IDPH
a. Completed Medical Questionnaire form
b. $40.00 registration fee made payable to IDPH
❏ If born outside of ILLINOIS, certified copy of birth certificate
❏ If a legal guardian, certified copy of court ordered guardianship
Birth Mother/Father
❏ Appropriate Registration Identification form
❏ Adoption Registry Application form
❏ Photocopy of photo identification
❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form
With one of the following:
With $40.00 registration fee made payable to IDPH
a. Completed Medical Questionnaire form
b. $40.00 registration fee made payable to IDPH
Surviving Relative of a Deceased Birth Parent (birth parent’s non-surrendered child, sister or brother)
❏ Appropriate Registration Identification form
❏ Adoption Registry Application form
❏ Photocopy of photo identification
❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form
With one of the following:
With $40.00 registration fee made payable to IDPH
a. Completed Medical Questionnaire form
b. $40.00 registration fee made payable to IDPH
❏ Certified copy of birth and death certificate of birth parent
❏ Certified copy of your birth certificate
Surviving Relative of a Deceased Adopted/Surrendered Person (adult child or spouse with a minor child)
❏ Appropriate Registration Identification form
❏ Adoption Registry Application form
❏ Photocopy of photo identification
❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form
With one of the following:
With $40.00 registration fee made payable to IDPH
a. Completed Medical Questionnaire form
b. $40.00 registration fee made payable to IDPH
❏ Certified copy of birth and death certificate of adopted/surrendered person
❏ Certified copy of the adopted/surrendered persons child’s birth certificate
❏ If spouse with minor child, certified copy of marriage certificate

Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY APPLICATION
Section C - Optional written statement
This optional written statement is authorized for release as specified in Section C of the Adoption History Application. This statement is limited
to the space (two pages) provided on this form and cannot include information that would identify any person other than the registrant submitting
the statement. This written statement will be reviewed by registry staff to verify compliance with the law. Registry staff must remove prohibited
identifying information or return the statement to the registrant for compliance. Please type, write clearly or print in dark blue or black ink. A
lined and unlined page are provided for your convenience. Both pages may be used.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161a (rev. 01/2000) Printed by Authority of the State of Illinois P.O. #145083 3M 9/04 IL482-1015

Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY APPLICATION
Section C - Optional written statement
This optional written statement is authorized for release as specified in Section C of the Adoption History Application. This statement is limited
to the space (two pages) provided on this form and cannot include information that would identify any person other than the registrant submitting
the statement. This written statement will be reviewed by registry staff to verify compliance with the law. Registry staff must remove prohibited
identifying information or return the statement to the registrant for compliance. Please type, write clearly or print in dark blue or black ink. A
lined and unlined page are provided for your convenience. Both pages may be used.
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161b (rev. 01/2000) Printed by Authority of the State of Illinois P.O. #145083 3M 9/04 IL482-1015

Illinois Department of Public Health
ADOPTED PERSON REGISTRATION IDENTIFICATION
(Enter all known information.)
I, ________________________________________________________, state the following:
(present name) (first) (middle) (last)
Adoptive name _____________________________________________________________
(first) (middle) (last)
Adopted person’s
birth name (if known)____________________________________________ Race _________
(first) (middle) (last)
Date of birth _____________ Sex _____ Hospital (if known) ___________________________________
City and state of birth ________________________________________________________
Name of
adoptive father ______________________________________________ Race _________
(if applicable) (first) (middle) (last)
Name of
adoptive mother _____________________________________________ Race _________
(if applicable) (first) (middle) (maiden) (last)
I was adopted through________________________________________________________
(name of agency)
(city and state of agency)
I was adopted privately________________(state “yes” if known)
I was adopted in____________________________________________
(city and state)
_______________
(approximate date)
Other identifying information___________________________________________________
__________________________________________________________________________
Name of
birth mother_________________________________________________
(if known) (first) (middle) (maiden) (last)
Name of
birth father _________________________________________________
(if known) (first) (middle) (last)
Race _________
Race _________
Provide name(s) at birth and ages of siblings(s) having a common birth parent with adopted
person (if known). If more than one sibling, please give information requested below on
reverse side of this form.
__________________________________________________________________________
(first) (middle) (last)
Date of birth__________________________________ Sex__________ Race _________
(or approximate age)
City and state of birth ________________________________________________________
Name(s) of common
birth parent(s) _______________________________________________ Race _________
(first) (middle) (last)
_______________________________________________
(first) (middle) (last)
Race _________
(Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, then you must submit a certified
copy of your birth certificate.)
_________________________________
(date)
_________________________________
(signature of adopted person)
_________________________________
(printed or typed name of adopted person)
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097

Illinois Department of Public Health
STATE OF ILLINOIS ADOPTION REGISTRY
INFORMATION EXCHANGE AUTHORIZATION
I, ______________________________________, state that I am the person who completed the
Registration Identification; that I am ______ years of age; that I hereby authorize the Department of
Public Health to give the following person(s) (check as applicable) ❏ birth mother ❏ birth father ❏ birth
sibling ❏ adopted/surrendered person ❏ adoptive mother ❏ adoptive father ❏ legal guardian of an
adopted or surrendered person ❏ birth aunt ❏ birth uncle ❏ adult child of a deceased adopted or
surrendered person ❏ surviving spouse of a deceased adopted or surrendered person ❏ all eligible relatives
the following information:
(please check the information authorized for exchange)
1. Only my name and last known address (as given below).
2. A copy of my Illinois Adoption Registry application.
3. A copy of the original birth certificate of the adopted person.
4. A copy of the completed medical questionnaire.
I am fully aware that I can only be supplied with information about the individual(s) who has duly executed
an Information Exchange Authorization that has not been revoked. I can be contacted by writing to:
(insert your own name, complete mailing address and telephone number
or this same information for another person to contact)
NAME
STREET ADDRESS
TELEPHONE NUMBER
( )
CITY STATE ZIP CODE
Dated __________________________, _________
(insert date)
______________________________________
APPLICANT’S SIGNATURE
STATE OF______________________________
COUNTY OF____________________________
If adoption agency representative, please state title.
____________________________________________
Name of agency ______________________________
City ________________________________________
State _________________ ZIP code _____________
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that
_______________________________ personally known to me to be the same person whose name is subscribed
to the foregoing Information Exchange Authorization, appeared before me in person and acknowledged that he/she
signed such authorization at his/her free and voluntary act and that the statements in such authorization are true.
Given under my hand and notarial seal on __________________________, _________
(insert date)
______________________________________
SIGNATURE OF NOTARY
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.7 (rev. 2/2006) Printed by Authority of the State of Illinois P.O. #146101 3M 2/06 IL482-1017

Illinois Department of Public Health
STATE OF ILLINOIS ADOPTION REGISTRY
DENIAL OF INFORMATION EXCHANGE
I, ______________________________________, state that I am the person who completed the
Registration Identification; that I am ______ years of age; that I hereby instruct the Department of
Public Health not to give any information about me to the following person(s) (check as applicable)
❏ birth mother ❏ birth father ❏ birth sibling ❏ adopted/surrendered person ❏ adoptive mother
❏ adoptive father ❏ legal guardian of an adopted or surrendered person ❏ birth aunt ❏ birth uncle
❏ adult child of a deceased adopted or surrendered person ❏ surviving spouse of a deceased adopted
or surrendered person ❏ all eligible relatives; that I do not wish to be contacted.
(Insert your own name, complete mailing address and telephone number or this same information
for another person you wish us to contact. This information is for administrative purposes only and will be
used to provide written confirmation that this denial has been filed.)
NAME
STREET ADDRESS
TELEPHONE NUMBER
( )
CITY STATE ZIP CODE
Dated __________________________, _________
(insert date)
______________________________________
APPLICANT’S SIGNATURE
STATE OF______________________________
COUNTY OF____________________________
If adoption agency representative, please state title.
____________________________________________
Name of agency ______________________________
City ________________________________________
State _________________ ZIP code _____________
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that
_______________________________ personally known to me to be the same person whose name is
subscribed to the foregoing Denial of Information Exchange, appeared before me in person and
acknowledged that he/she signed such authorization as his/her free and voluntary act and that the statements
in such authorization are true.
(insert date)
Given under my hand and notarial seal on __________________________, _________
______________________________________
SIGNATURE OF NOTARY
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.8 (rev. 2/2006) Printed by Authority of the State of Illinois P.O. #146100 3M 2/06 IL482-1020

(Enter all known information and add explanation/comments as necessary.)
A. CONGENITAL IMPAIRMENTS
Yes
1. Club foot or any other orthopedic problem ❑
2. Cleft lip or cleft palate
❑
3. Chromosome abnormality (explain)
❑
4. Down’s syndrome
❑
5. Muscular dystrophy
❑
6. Spina bifida
❑
7. Congenital heart defect
❑
8. Tay-Sachs disease
❑
9. Fetal alcohol syndrome
❑
10. Trisomy 21
❑
11. Ambiguous genitalia
❑
12. Hydrocephalus
❑
13. Macrocephalus
❑
14. Amencephalus
❑
15. Microcephalus
❑
16. Other (explain)
❑
B. ALLERGIES
1. Eczema or other skin condition
❑
2. Hay fever or other allergy
❑
3. Drug allergy (to what drugs?)
❑
4. Other (explain)
❑
C. EYE AND EAR DISORDERS
1. Blindness, glaucoma, color blindness or ❑
other visual problems
2. Deafness or other ear problems
❑
3. Other (explain)
❑
D. BLOOD AND CIRCULATORY DISORDERS
1. Hemophilia
❑
2. Sickle cell anemia or trait
❑
3. Anemia
❑
4. Hypertension (high blood pressure)
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5. Stroke
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6. Heart attack
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7. Arthritis
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8. Kidney disease
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9. Other (explain)
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E. RESPIRATORY DISORDERS
1. Asthma
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2. Tuberculosis
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3. Emphysema
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4. Cystic fibrosis
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5. Bronchial pulmonary disposia
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6. Other (explain)
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Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY – MEDICAL QUESTIONNAIRE
No
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If answering “yes” to any item, specify item number (for example, A2, B4, etc.) and indicate self or family member.
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097

F. HORMONAL DISORDERS
1. Diabetes
2. Thyroid disorder
3. Other (explain)
Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY – MEDICAL QUESTIONNAIRE
Yes
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No
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If answering “yes” to any item, specify item number (for example, A2, B4, etc.) and indicate self or family member.
G. MENTAL AND BEHAVIORAL DISORDERS
1. Schizophrenia
2. Manic depressive (bi-polar)
3. Clinical depression
4. Substance abuse (adopted person or birth parent)
(list type and explain)
5. Obsessive-compulsive disorders
6. Eating disorders
7. Drug usage
8. Autism
9. Other (explain)
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H. MALIGNANT DISORDERS
1. Cancer (specify site)
2. Tumors
3. Hodgkin’s disease
4. Other (explain)
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I. NERVOUS SYSTEM DISORDERS
1. Multiple sclerosis
2. Huntington’s disease
3. Cerebral palsy
4. Seizures or convulsions
5. Epilepsy
6. Other (explain)
J. INFECTIONS AND HOSPITALIZATION (explain)
1. Repeated attacks of fever with known infection
2. Repeated severe infection requiring
hospitalization
3. Hospitalizations or operations, if any
4. HIV/STDs (herpes, syphillis, etc.)
5. Hepatitis
6. Other (explain)
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K. DEVELOPMENTAL DELAYS
1. Speech challenged
2. Learning challenged
3. Mentally challenged
4. Physically challenged
5. Other (explain)
L. OTHER IMPAIRMENTS, DISEASE OR DISORDERS
(metabolic, genetic or other) [Including ALS (Lou
Gehrig’s disease), gout, obesity, etc.] (list and explain)
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RELEASE: On the Information Exchange Authorization Form, the registrant may authorize the release of the information
from this medical questionaire.
DISCLAIMER: The Illinois Department of Public Health cannot guarantee the accuracy of medical information
exchanged through the Adoption Registry as the information is submitted by the registrants, not the Department.
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.9 (rev. 05/2000) Printed by Authority of the State of Illinois P.O. #145082 3M 9/04 IL482-1018

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