Adoption Home Study Sample

November 1, 2001

Smith, John (d.o.b. 2-12-60)
Social Security # 123-77-0000
Driver's License KS #KS123
Smith, Lisa (d.o.b. 5-30-61) 
Social Security #123-76-0000
Driver's License KS #KS234

123 Pleasant Street, Anywhere, Kansas 66212


123-555-1111 (home)
123-555-2222 (Work, husband) Pleasant High School 
123-555-3333 (Work, wife) Pleasant Elementary

April 12, 1983 (Confirmed via marriage license #345)


Take interstate 35 to the Anywhere exit. Go south to Pleasant Street. Third house on the left

Mr. and Mrs. Smith contacted our agency for the purpose of a domestic adoption of a newborn Caucasian infant.

They were referred to our agency by the yellow pages. They had been considering adoption for several years. They tried twice through a lawyer, but both times the birth parents choose to parent the infant rather than place for adoption.

October 12, 2001
October 24, 2001
October 31, 2001


DATE OF BIRTH: 2-12-60 5-30-61
PLACE OF BIRTH: Fort Worth, TX Kalamazoo, MI
EDUCATION: BS Education BS Education
OCCUPATION: Teacher Teacher
EMPLOYER: San Marcus High San Marcus Elementary
DATE OF MARRIAGE: 4-12-83 Same
RELIGION: Baptist Baptist
AGE: 32 years 31 years
HEIGHT: 6 ft. 1 in. 5 ft. 1 in.
HAIR COLOR: Sandy Blonde Brown
EYE COLOR: Brown Blue
RACE: Caucasian Same
DECENT: English/German English/German/Cherokee
BODY STRUCTURE: Medium Bone Small Bone
COMPLEXION: Medium Medium

John Smith was born on February 12, 1960, in Pleasant, Kansas (confirmed with birth certificate). He was the first of three children for Jim and Mary Smith. His father, age 65, was a successful banker, now retired. His father's success allowed his mother, age 63, to stay home and raise their children full time. He has a sister Sheila and a brother Ronnie, 29 and 25 respectively. Sheila lives with her spouse Billy Jones and their two children, Ann and Andy, in Mayberry, Kansas. Ronnie is obtaining a degree in Music from Pleasant University and is currently single. They are all in excellent mental and physical health.

John grew up in a very family oriented environment. They all regularly attended Church Of Pleasant, where they were actively involved in both church and community functions. Being a close-knit group the entire family would attend any activity involving another member. They also took vacations together, whether it was a long weekend to go camping or a few weeks during the summer to see some part of the country. One of his favorite trips was to the Grand Canyon. As a young man he was encouraged to be involved with school clubs and sports, as a result he had many friends. All his friends were always welcome in their home to participate in the family's festivities.

As a child singing in the church choir, John, first realized his love for music and has gone on to have several songs published. In addition to writing music, he enjoys reading and landscaping their yard. He has planted several trees and flowerbeds while maintaining a flourishing garden. He still enjoys playing sports and is involved along with Lisa in church volleyball and softball leagues. Although you will hear John joke, "Lisa can't play! She runs from the ball if it comes near her!" She really is a good ball player. Occasionally he will play racquetball or basketball at the community center.

John says he grew up in a wonderful and loving environment and hopes to provide the same for his children. He is still very close to his family and they normally get together every couple of weeks to have a bar-b-que. He describes himself as an out-going, musically inclined, faithful, and caring man, who believes family is the most important thing in life.

John is a graduate of Pleasant University with a degree in Music Education in 1983. He graduated with honors.

John is a music teacher for a Pleasant High School. (Confirmed) He has been with this school since his college graduation in 1983. In the summer, he works as a part time salesman for Sears.

Lisa Smith was born May 30, 1961 in Pleasant, Kansas. She is thirty-one years old and the middle child of Lloyd and Marcia Coates. After forty years as a manufacturer's representative for several machine tool companies, her 64-year-old father plans to retire next year. Besides high blood pressure that is thought to be a result of being overweight, her father is in good health. Lisa's mother is 62 years of age and also in good health. She is employed as a part time occupational therapist that plans to retire at the same time as Lloyd. Regarding siblings, Lisa has a brother and a sister, named Curtis and Cathy. Curtis is thirty-five and married Joan. They have three lovely daughters. JoAnn is ten. Cindy is eight. Marci is four. They live in Anywhere, Texas. Cathy is twenty-nine and married John Logan. They have one son, Ben who is three. They live in Anywhere, California.

While she was growing up, Lisa always felt special to her parents. Often atypical to the middle child, Lisa never felt overlooked or unloved. Religion was important but not a dominant force in her upbringing. It was common for her father to frequently travel because of his job. Lloyd despite his time away always seemed to find the time to take the family on an annual two-week vacation. He also arranged for them to go on numerous business trips with him over the summer. Even though Lloyd traveled and was often away from home, Lisa still felt he greatly influenced her life. Lisa's mother always made the best out of the worst situation. It was not uncommon for her mother to make Lisa and Cathy's clothes.

Lisa was involved with numerous school activities while growing up. She was active in a group called "Rainbow" girls. Lisa loved theater and auditioned for all school theatrical productions. It was normal for Lisa to acquire the lead roles in most productions. Beyond theater, she enjoyed singing, sewing, knitting, watching TV, and playing softball. Lisa was a very good athlete and she still boasts that she can catch a ball better than John can.

Lisa's family was then and still is very close. She has fond memories of her childhood. Lisa does not see her brother as much as she would like, but understands the chaos that managing three children can bring. Lisa is generally closer now with her sister Cathy. They usually talk at least every two weeks.

Lisa graduated in 1984 with her bachelor's degree in elementary education from Pleasant University.

Lisa has been employed since 1984 as a third grade elementary teacher at Pleasant Elementary in Pleasant, Kansas. (Confirmed). She plans on quitting her job upon placement of a child. She plans to resume teaching once her child is old enough to start school.

Reverend Fred Swank married the Smiths April 12, 1983 at Pleasant Church, in Anywhere, Kansas. (Confirmed by marriage certificate).

John and Lisa met while attending Pleasant University. After only a few dates, they decided to date exclusively. Lisa states it was "love at first sight". For John, the love grew greater with the passing of each day. John wanted his feelings for Lisa to grow, but he did not want to lose sight of completing school. After graduation, he made plans to marry Lisa.

Lisa and John family backgrounds were very similar. John and Lisa share similar hobbies. When either is involved in separate activities the other is very supportive. Lisa and John both feel that they can discuss anything and naturally share their most intimate feelings. They feel they are "best friends".

The Smith's home is tucked away on a quiet residential street located in the town of Anywhere, Kansas. Their neighborhood is pleasantly supported with good neighbors and children of all ages. Their church and school are both within walking distance of their home.

Their home is two stories. The first floor contains a living room, dining room, kitchen, laundry room and half bath, and a small room that can be used as a playroom. The second floor contains three bedrooms with walk in closets and a full bath. The home is tastefully furnished and housekeeping standards are good.

The Smith's are buying their home. They have lived at this address for the past three years.

John is in good health. He had the usual childhood illnesses. He has experienced no surgery or serious illness. (Confirmed by physician Dr. Good's report). 
Lisa is in good health. She had the usual childhood diseases. She has had extensive treatment for her infertility. She is physically capable of parenting a child. (Confirmed by physician Dr. Sullivan).

The Smith's have a gross combined annual income of $64,000 with a net income of $56,000. (Verified by IRS statements) John has an annual gross income of $32,000. Lisa has an annual gross income of $32,000 as well.

They have $201, 863 in assets. This consists of $9,000 in cash savings and checking accounts, $1,358 in life insurance cash value, $5,500 in stocks and bonds, $2,369 in a tax escrow fund, and $86,605 vested in a retirement plan through both of their employers. Their home is valued at $58,0000 and they have a thirty-year mortgage. They pay $383 a month on the mortgage and that includes insurance. Together with car payment, house payment, utilities, food, insurance, etc. they pay out approximately $895 per month. They have enough left over that they can well afford a child into their family.

LIFE: John has life insurance with Pleasant Mutual Life valued at $100,000.00. Lisa has life insurance with the same company valued at $50,000.000. 
HEALTH: They are covered with Pleasant Shield Major Medical. (Verified) It covers the baby from time of placement. They must wait twelve months for pre-exiting conditions.

The Smith's are active members with a strong commitment to their church, Pleasant Church. On Sundays, John and Lisa sing in the church choir. Lisa is active in the Church Missions Group. It is normal for John to make pancakes every Sunday before church. Their son Trey goes to church and so too will all their children.

The Smith's have a son, John (Trey) Smith who was born on February 14, 1989 after a very difficult pregnancy and an emergency c-section delivery. John goes by the nickname Trey. John and Lisa liked the nickname, so they put it on his birth certificate so Trey could legally use that name. He is 3 foot 2 inches tall, relatively short for his age. He has brown hair, brown eyes, and a small frame. He is in excellent health besides having numerous ear infections as a baby.

Trey's captivating personality coupled with his remarkable intelligence makes for a wonderful young man. He listens and obeys his parents very well. He enjoys playing with his toy trucks and watching Sesame Street. He knows about his parent's adoption plan and is excited to welcome a baby brother or sister into the family.

The Smith's are excellent loving parents. Trey receives appropriate suggestions for his age as well as proper punishment by way of time out. Talking and explanations are ways John and Lisa help Trey to learn right from wrong. They generally enjoy family outings and often involve Trey in the planning's of such outings. Trey constantly suggests picnics!

Two days a week, the Smith's send Trey to a day care. The other three days a week he stays with a licensed day care provider while the Smith's are teaching. During the summer, he stays at home with his mother.

In case of untimely deaths, the Smith's select John's sister and brother-in-law, Sheila and Danny Jones of Anywhere, Texas to be the legal guardians of their children. They feel Mr. and Mrs. Jones would be wonderful parents because they currently have two lovely children. They additionally are financially secure as Danny has a career as an attorney. The Smiths currently are in the process of making a will.

John and Lisa have known from the beginning of their marriage that they may need to adopt. Lisa suffers from fibroid tumors (benign) which prevents many women from becoming pregnant. While she was able to conceive one biological child, Trey, their doctor referred to their pregnancy as a once in a lifetime birth "miracle". Through numerous discussions, they feel certain that an adopted child would receive equal opportunities and love as their biological child. Pursuing infertility with all the physically and emotionally draining tests is not an appealing option when contrasted to that of adoption. They have attended Resolve meetings and have a really good attitude about their infertility.

The Smith's have successfully handled the infertility issue of Lisa's fibroid tumors. They endured several tests and surgical techniques in their efforts to try and correct the tumors. After unsuccessful surgeries and tests, they began visiting their local Resolve group and have remained active to date. They decided against further medical intervention as they feel their primary purpose is to parent. They feel the pursuit of further infertility testing is a waste of their time and energy. The Smiths have shared their infertility and adoption plans openly with friends and family.

John and Lisa Smith have negative records for felony and child abuse charges.

All references have been very good and supportive of the Smith's plans to adopt. One reference said, "It would be a sin if they were not allowed to adopt a baby". Letters were obtained from four friends and their minister. They were Ed Smith of Anywhere, Texas; Mrs. John (Brenda) Betts, Anywhere, Kansas; Mr. and Mrs. Gary Carver, Anywhere, Kansas; Mrs. Jim (Sheila) Page, Anywhere, Kansas and Rev. Sam Peterson, Anywhere, Kansas.

The Smith's are willing to meet with the birth parent if that is their desire. They wish to be identified only on first name basis. They are willing to send pictures and letters to the birth parent(s) as well as receive letters from the birth parent(s) via the adoption agency. They feel comfortable sending letters and pictures every three months for a year. At the end of that year, they will then decide if they will continue contact.

The Smith's will consider a boy or girl from a newborn to a toddler. They will consider only a Caucasian child. It is possible Lisa and John will accept a child with mild handicaps such as clubfeet, cleft palate, etc. They, however, will not accept a child with any neurological or mental handicaps. It was explained to them that it is often impossible to determine such neurological and most mental handicaps at birth.

I feel the Smith's are sincerely motivated in their desire to adopt a child. After my contacts with John and Lisa, I find them to be mature, well-adjusted couple with a strong desire to parent. It is my recommendation that an adopted child would greatly benefit the Smith's. It is easy to conclude that a child would be welcomed into a loving, stable family and would be given every opportunity to grow into his/her own person. I do not hesitate to recommend John and Lisa Smith as good prospective adoptive parents.

Signed, Dated, and Notarized by Social Worker and/or Executive Director

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