Adult Relative of a Deceased Birth Parent Forms - The Cradle

If you are requesting:2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Checklist for PostAdoption ServicesBackground History ReportBrief Update ReportBirth Parent ReportYou will need to returnFee Schedule (with payment if applicable)Client Identification Form (signed)Copy of valid photo identificationWhat Every Client Should KnowLetter (signed)Privacy Acknowledgment Form(signed)Copy of Illinois Adoption RegistryMedical Questionnaire (required forbirth family, optional for others)Mutual Consent RegistryYou will need to returnFee Schedule (with payment if applicable)Client Identification Form (signed)Copy of Valid photo identificationWhat Every Client Should KnowLetter (signed)Privacy Acknowledgment Form(signed)Copy of Illinois Adoption RegistryMedical Questionnaire (required forbirth family, optional for others)Information Exchange AuthorizationForm (Notarized)“Your first letter” (optional)SearchYou will need to returnDescendent of a deceased adopted person and the survivingrelative of a deceased birth parent must provide copy of deathcertificate or obituary and proof of relationship for anyservice request.Fee Schedule (with payment)Client Identification Form (signed)Copy of Valid photo identificationWhat Every Client Should KnowLetter (signed)Privacy Acknowledgment Form(signed)*Copy of Illinois Adoption RegistryConfirmation LetterCopy of Illinois Adoption RegistryMedical Questionnaire (required forbirth family, optional for others)Information Exchange AuthorizationForm (Notarized)“Your First Letter”Personal History & BiographyQuestionnaire(*Before requesting a Search, registrationwith the State of Illinois is required. Go towww.idph.state.il.us for forms.)12/11 x:/Materials/Post Adoption/Forms/Checklist.doc

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Fee SchedulePost Adoption ServicesYour Full Name (please print): ___________________________________________________ Date: ________________Requested Service(s)Non-Identifying Information Background History Report (DOB 1923-1940) $50Fees Background History Report (DOB 1941-present) $125Registryreceived background information) $50 Birth Parent Report (for Birth Parents only) $0 Registry with Medical Questionnaire $0 Registry without Medical Questionnaire $15Reaching Out Basic Search $225 Extended Search (if Basic Search is unsuccessful) $300 Reconnection $50Brief Update (if you have previouslyCounseling/Consultation In person By phone Mediation at The CradleCommunity Services Training$110 (per hour)$110 (per hour)(Prorated by 1/2 hour)$110 (per hour)contact us for more informationPayment MethodCheck made out to The Cradle enclosedTotal 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 847-475-5800Client IdentificationYour Name (First, Middle, Last)_____________________________________________Your Date of Birth_____________________ Your Social Security Number (optional):______________Are you a/an:Adult Adopted Person (21 or older)Birth MotherBirth FatherAdoptive Parent(s)Birth Sibling adopted2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Adult descendant of a deceased AdoptedPersonSpouse of a deceased Adopted PersonAdult relative of deceased Birth ParentOther eligible relative_______________Street Address______________________________________City, State, Zip CodeEmail address:______________________________________Home phone number:____________________________Cell phone number:_____________________________Work phone number:____________________________Best place to reach me (circle one): homecell workAdopted Person’s date of birth:___________________Name(s) of Adoptive Parents at the time of theadoption:______________________________________ORBirth Mother’s date of birth:______________________Name(s) of Birth Parents at the time of theadoption:____________________________________________________________________________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

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Other 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 adoptiveparent(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 acopy of my/our photo ID(s).Signature:Date:I would like to receiveGeneral Cradle Newsletter □ Yes □ NoCradle e-newsletter □ Yes □ No12/11 x:/Materials/Post Adoption/Forms/Client Identification.doc

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800When you have a concern you should share it with your social worker. If you are morecomfortable 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 ofcommunication open. Thus, you should expect that the supervisor will share your concernwith your social worker. Open discussions can often address the concern and resolve theissue satisfactorily. If, however, you are not satisfied with the outcome after thesediscussions, you may initiate a formal Problem Resolution Process.When beginning the formal Problem Resolution Process, take the time to describe, inwriting, the nature of your concern and forward it to the Executive Director of AdoptionServices (“Executive Director”). The Executive Director will initiate an investigation ofyour complaint within 2 business days upon receipt of the complaint. The ExecutiveDirector will share your complaint with your social worker and his/her supervisor anddiscuss your concerns and determine whether correctable action is indicated. You may beasked 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 ona variety of factors including the availability of all the staff members involved, but in noevent will it be longer than 10 business days unless extenuating circumstances exist whichrequire additional time for resolution. Should this occur, you will be notified at least by dayten of the need to continue the investigation.As required by law, the Agency will report the outcome of its complaint investigation inwriting to the Department of Children and Family Services (DCFS) regional licensing officeor the DCFS Licensing Representative within 10 business days after complaints arereceived unless extenuating circumstances exist which require additional time forresolution. 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 andresolution 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 847-475-5800The CradleNotice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USEDAND 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). Thisinformation may identify you and relates to your past, present or future physical or mental health condition andrelated health care services is referred to as Protected Health Information (“PHI”). This Notice of PrivacyPractices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Codeof 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 dutiesand privacy practices with respect to PHI. We are required to abide by the terms of this Notice of PrivacyPractices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Anynew Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We willprovide 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 YOUFor Services. Your PHI may be used and disclosed by those who are involved in your care for the purpose ofproviding, coordinating, or managing your services. This includes consultation with clinical supervisors orother 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 businessactivities including, but not limited to, quality assessment activities, employee review activities, licensing, andconducting or arranging for other business activities. For example, we may share your PHI with third partiesthat 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, wemust make disclosures to the Secretary of the Department of Health and Human Services for the purpose ofinvestigating 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 aboutyou without your authorization only in a limited number of other situations. Examples of some of thetypes of uses and disclosures that may be made without your authorization are those that are:Based largely on text provided by theNATIONAL ASSOCIATION OF SOCIAL WORKERSDOCUMENT D2© Popovits & Robinson, P.C. Page 1 of 24-2003X:\Materials\HIPAA Client Forms\HIPAA Client Notice of Privacy Practices.doc

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory governmentagency 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 thepublic. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a personor persons reasonably able to prevent or lessen the threat, including the target of the threat. Verbal PermissionWe may use or disclose your information to family members that are directly involved in your receipt ofservices with your verbal permission.With Authorization. Uses and disclosures not specifically permitted by applicable law will be made onlywith your written authorization, which may be revoked.YOUR RIGHTS REGARDING YOUR PHIYou 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 PresidentHuman 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 exceptionalcircumstances or with documents released to us, to inspect and copy PHI that may be used to makedecisions 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 mayask 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 ofthe disclosures that we make of your PHI. We may charge you a reasonable fee if you requestmore than one accounting in any 12-month period. Right to Request Restrictions. You have the right to request a restriction or limitation on theuse or disclosure of your PHI for services, payment, or business operations. We are notrequired to agree to your request. Right to Request Confidential Communication. You have the right to request that wecommunicate with you about PHI matters. Right to a Copy of this Notice. You have the right to a copy of this notice. COMPLAINTSIf you believe we have violated your privacy rights, you have the right to file a complaint in writing withour Privacy Officer at The Cradle or with the Secretary of Health and Human Services at 200Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliateagainst you for filing a complaint.The effective date of this Notice is April 14, 2003.Based largely on text provided by theNATIONAL ASSOCIATION OF SOCIAL WORKERSDOCUMENT D2© Popovits & Robinson, P.C. Page 2 of 24-2003X:\Materials\HIPAA Client Forms\HIPAA Client Notice of Privacy Practices.doc

Notice of Privacy PracticesReceipt and Acknowledgment of Notice2049 Ridge Avenue, Evanston, IL 60201 847-475-5800Client Name:_____________________________________________DOB: ___________________________________________________SSN (Optional):___________________________________________I hereby acknowledge that I have received and have been given an opportunity toread a copy of The Cradle’s Notice of Privacy Practices. I understand that if I haveany questions regarding the Notice or my privacy rights, I can contact MerrileeHepler, Vice President, Human Resources & Administration and Risk ManagementOfficer, located at The Cradle, 2049 Ridge Ave., Evanston, IL, 60201, 847-733-3223._________________________________________________________________Signature of ClientDate_________________________________________________________________Signature of Parent, Guardian or Personal Representative Date__________________________________________________________________• If you are signing as a personal representative of an individual, please describe yourlegal authority to act for this individual (For example, power of attorney).₃ Client Refuses to Acknowledge Receipt:_________________________________________________________________Signature of Staff MemberDateX:\Materials\HIPAA Client Forms\HIPAA Receipt & Acknowledgement Notice.doc

Information Exchange AuthorizationI/We, _________________________________________, state that I/we am/are the person/people whocompleted the Client Identification; that I am ______ years of age; that I hereby authorize The Cradle togive the following person(s): (check as applicable)Adult adopted person (21 or older) Birthmother Birthfather Adoptive Parent(s) BirthSibling adopted Adult descendant of a deceased Adopted Person Spouse of a deceased AdoptedPerson Adult relative of deceased Birth Parent all eligible relativesthe following information:(please check the information authorized for exchange)Release my name and contact information on this document, and/or the most recent contactinformation 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 ContactedStreet AddressHome Phone___________________Cell PhoneCity, State, Zip CodeE-mailSignatureDatePlease 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 thatis personally known to me tobe the same person whose name is signed to the foregoing Information Exchange Authorization, appearedbefore me in person and acknowledged that she/he signed such certificate as her/his free and voluntary act andthat 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 847-475-5800When a birth relative is located, the question is often, "what do we do now?" While manypeople want to meet right away, our experience has taught us that often the best reunions arethose 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 asdeal 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 containany identifying information. This letter is an opportunity for you to introduce yourself. Youmay wish to include a brief summary of major events in your life, as well as a statement abouthow your adoption experience has affected your life. It will also be important to include whatyou are hoping for from this contact. Many people, when first located, feel more comfortablebeginning contact with letters and photos exchanged confidentially and anonymously throughThe 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 yourlast name, address, phone number, or email in this letter. It is best to wait until both you andyour birth relative are comfortable before releasing this information.For photographs, you may wish to include several of yourself from childhood through thepresent. In addition, if you have children you are parenting or have parented, you may wish toinclude photos of them. If you do not want to part with certain photos (for example of yourselfas a child), you could send color photocopies. Please do not select photographs of yourself inwhich you are wearing sunglasses.If we are able to locate your birth relative, we will make this letter available to him or her. Ifwe are not able to locate your birth relative, or if your birth relative is not open to receivingyour 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 firstintroduction to you as a person. Keep in mind that you cannot say everything in one letter, andthat too much information can be overwhelming for the recipient. Hopefully, this will be thefirst of many contacts. If you would like us to review a draft of your letter, please feel free tosend, email, or fax it to us. Remember that it does not have to be perfect, just sincere. Themost important thing of all is just to start writing!

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800--------------------------------------------------------------------------------------------------------------------------------------------------------------------Personal History & Biography QuestionnaireSurviving Relative of Birth ParentWhen we are working on your behalf, making an outreach or searching for the adopted person, it ishelpful to have some information about you and the birth parent. This information assists us in servingyou throughout the process. Additionally, we are better able to represent you to the adopted person,should we be able to locate him/her and make contact. Our being able to provide some informationabout the birth parent, and about you, will assist them in making a decision about being open to havingcontact with you.Please write a paragraph or two sharing some information about the birth parent, including but notlimited to: thoughts and feelings about placing a child for adoption, relationship with his/her family,hobbies, interests and skills, accomplishments including education and employment, personal lifeincluding marriage and family life. Did he/she speak of the circumstances surrounding the pregnancyand the decision to make a plan of adoption? Did he/she ever think about searching? Please feel freeto include information about yourself as well.Please share also your thoughts and feelings about this process. How did you decide to search? Whatdo you imagine would be the best outcome and the most difficult outcome? Who knows of yourdecision to proceed with this search? What are your primary means of emotional support? Are thereany medical concerns in your family history that you would like to share? Is there any additionalinformation we should know about you in order to assist you throughout this process?