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CPS Adoption Information Sheet

"*" indicates required fields

Adoptive Parent(s)

Adoptive Parent 1

Current Legal Name*

First Middle Last

Name as Appears on Birth Certificate*

First Middle Last

Do you use a title with your name such as Dr. or Rev.?*

Yes

No

Title*

Date of Birth*

MM slash DD slash YYYY

Place of Birth*

Social Security Number*

Cell Phone Number*

Email Address*

Is there an additional parent?*

Yes

No

Adoptive Parent 2

Current Legal Name*

First Middle Last

Name as Appears on Birth Certificate*

First Middle Last

Do you use a title with your name such as Dr. or Rev.?*

Yes

No

Title*

Date of Birth*

MM slash DD slash YYYY

Place of Birth*

Social Security Number*

Cell Phone Number*

Email Address (Must be different from email above. We use DocuSign for final documents which requires different emails for each parent.)*

Additional Information Concerning Adoptive Parent(s)

Address at time of child's birth*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Current Mailing Address*

Street Address Address Line 2 City State ZIP Code

Is your address within city limits?*

Yes

No

Names and age of all children living in home including child to be adopted*

Information on child to be adopted

Name on Birth Certificate*

First Middle Last

Name that you want the child to have*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Place of Birth*

City*

County*

State*

Hospital of Birth (if known)

Date of Child Was Placed with You*

MM slash DD slash YYYY

Is the child eligible for a subsidy?*

Yes

No

Birth Mother of Child

Birth Mother's Full Legal Name (if known)

First Middle Last

Birth Father of Child

Birth Father's Full Legal Name (if known)

First Middle Last

Agency Information (if applicable)

Name of Agency

Phone Number

Contact Person at Agency

First Last

Social Worker

Name of social worker (who did your home study)*

First Last

Phone Number*

Email Address*

CPS Caseworker

Name of Caseworker*

First Last

Phone Number*

Email Address*

County the Termination of Parental Rights took place:*

Human Check

Δ

Location

Our Clients

“The adoption team was available to answer our questions quickly and made us feel comfortable in what can be, at times, an incredibly stressful situation. They helped us prepare for everything and really lead us in the right direction. We honestly don’t know where our family would be without all of their hard work, dedication, and passion for helping to create “forever families." - Travis & Toby Clayton

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Brown Pruitt Wambsganss Dean Forman & Moore, P.C. gathers, stores, and electronically transmits medical records (Protected Health Information or PHI) in the course of our representation of our clients, we are required to post notice to clients that their Protected Health Information is subject to electronic disclosure.

Texas law prohibits any electronic disclosure of a client's Protected Health Information to any person without a separate authorization from the client or the client's legally authorized representative for each disclosure. This authorization for disclosure may be made in written or oral form if it is documented in writing by our law firm.

The authorization for electronic disclosure of Protected Health Information described ab ove is not required if the disclosure is made: to another covered entity, as that term is defined by section 181.001 of the Texas Health Code, or to a covered entity, as that term is defined by Section 602.001 of the Texas Insurance Code, for the purpose of: treatment, payment, health care operations, performing an insurance or health maintenance organization function described by Texas Insurance Code Section 602.053; or as otherwise authorized or required by state or federal law. This means that no release is necessary for electronic disclosure to other health care providers, insurance companies, governmental agencies, or attorneys representing adverse parties.