General Data Sheet

For Prospective Clients

Please complete the data sheet below and return it to our office prior to your appointment. You may select “submit” at the bottom of the form to send it directly to our office via email or you may print the completed page and fax it to us at 865.933.3272 or mail it to us at P. O. Box 388, Strawberry Plains, TN 37871.

If you would feel more comfortable providing this information by phone, please let us know. We will be happy to do that.

Please complete the information applicable to your case and submit. When your submission is complete, you will see: “Thank you for sharing your information.”

Appointment Date / Time
Parent 1

First Middle Last (Maiden, if applicable)
Parent / Prospective Parent 2

First Middle Last (Maiden, if applicable)
Parent 1 Preferred Name
Parent 2 Preferred Name
Primary Contact for Case
- Parent / Prospective Parent 1
- Parent / Prospective Parent 2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Marriage (if applicable)
Parent 1 Cell Phone Number
Parent 2 Cell Phone Number
Parent 1 DOB
Parent 2 DOB
Parent 1 Place of Birth
Parent 2 Place of Birth
Parent 1 Race
Parent 2 Race
Parent 1 Occupation
Parent 2 Occupation
Parent 1 Email
Parent 2 Email
Name of Home Study Agency / Worker (if any)
Placing Agency (DCS or Agency)
Notes / Comments / Summary of Case / Reason for Appointment
Child Information
Child 1 Full Birth Name
Child 1 Adoptive Name
Child 1 Date of Birth and State of Birth
Child 1 Race
Child 2 Full Birth Name
Child 2 Adoptive Name
Child 2 Date of Birth and State of Birth
Child 2 Race
Child 3 Full Name
Child 3 Adoptive Name
Child 3 Date of Birth and State of Birth
Child 3 Race
Date child/children came to live in your home?
Do any of the children own any real or personal property?

(such as bank accounts or social security)
Does any child have Native American Heritage?
Are you related to the child(ren)I? If so, how?
Children 14 or over must consent to their own adoption.
- Yes
- No
If any of your children are age 14 or over at the time of the adoption finalization, are they capable of consenting before the Judge or Chancellor?
Birth Parent Information
Full Name of Birth Mother for each child (if not listed above).
Describe the Mother(s) - Location / Visitation / Support History / Criminal or Mental Health History
Full Name of Biological Father (if not listed above.)
Describe the Father - Location / Visitation / Support History / Criminal or Mental Health History
Were the birth parents married?
- Yes
- No
- Unknown
Were the birth parents married?
If applicable, list any other possible legal or biological fathers.
Court Actions / Other Professionals
List all previous court actions regarding the child(ren). (Include the name of the court, the action type and the docket number, if known.)
What county Juvenile Court is involved?
List any other attorneys, GALs, social workers, and agencies involved. List any upcoming hearing dates.
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Birth Certificate(s), Important Court Documents, etc.
Email
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General Data Sheet

For Prospective Clients

Please complete the information applicable to your case and submit. When your submission is complete, you will see: “Thank you for sharing your information.”

Child Information

Birth Parent Information

Court Actions / Other Professionals

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