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Adoption Reference Questionnaire
Adoption Reference Questionnaire
ADOPTION REFERENCE QUESTIONNAIRE
Case Name: Case Number:
Name of the party for whom you are completing the questionnaire:
Instructions:
As you answer each question, please keep in mind that it is the responsibility of the court to safeguard the welfare and future
development of the child/ren in this family. You can help the court in meeting this responsibility by being objective and
confining your statements to observations which you personally have made. Answer each question as completely as possible,
using additional paper if needed. Please complete the form as soon as possible. Return the form to:
Donald LaFave Mediation & Counseling, LLC.
316 5
th
Street, Suite 3
Racine, Wisconsin 53403
Your Name: _____________________________________________ Home Telephone: __________________________
Street: _____________________________________________ Work Telephone: __________________________
City: _____________________________________________ State: ____________ Zip Code: _____________
Your relationship to the parties (friend, relative, employer, etc.): ________________________________________________
_____________________________________________________________________________________________________
How long have you known the parties above ________________________ Date last seen: _________________________
How often do you see them _____________________________________________________________________________
How long have you known the child/ren in this case _________________________ Date last seen: _________________
How often do you see them _____________________________________________________________________________
A. Physical Environment
: Please describe the home of the parties for whom you are a reference, including living conditions,
housekeeping standards, and surrounding neighborhood.
B. Care of Children
: Describe how the parties for whom you are a reference treats the child/ren, including attention to
cleanliness, clothing, meals, discipline, supervision, school involvement, and extra curricular activities, etc.
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source: donaldlafave.com
Adoption Reference Questionnaire
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