Consultation Form

Please complete the following consultation form to schedule a free, individual, no obligation, office visit with our Founder & Director Steffany Aye.

• Steffany will provide you with an in depth face to face consultation that will cover the six different types of adoption. Our consultation will help streamline everything you have been reading, researching and learning from the internet and from others in your life. It is our hope that you will find the office consultation beneficial and will provide you with the information needed to choose the avenue(s) of adoption that is right for your family.      
  
• Our consultations are reserved for office visits only and with both the husband and wife present, if married. 
  

Prospective Adoptive Father Ap 1 LAST Name * Ap 1 FIRST Name * Ap 1 Middle Name Ap 1 Preferred FIRST Name If different from Legal First Name Ap 1 DOB * Ap 1 Citizenship United States Australia Canada China Ethiopia France Germany Guatemala India Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine Show All Countries Ap 1 Occupation * Ap 1 Work Phone ()-ext Enter International Number Ap 1 Cell Phone ()-ext Enter International Number Ap 1 Primary Email Ap 1 Secondary Email Ap 1 Preferred Contact Method Any Cell Work Home Primary E-Mail Address Secondary E-mail Address   Prospective Adoptive Mother Ap 2 LAST Name * Ap 2 FIRST Name * Ap 2 Middle Name Ap 2 Preferred FIRST Name If Different from Legal First Name Ap 2 DOB * Ap 2 Citizenship United States Australia Canada China Ethiopia France Germany Guatemala India Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine Show All Countries Ap 2 Occupation * Ap 2 Work Phone ()-ext Enter International Number Ap 2 Cell Phone ()-ext Enter International Number Ap 2 Primary Email Ap 2 Secondary Email Ap 2 Preferred Contact Method Any Cell Work Home Primary E-Mail Address Secondary E-mail Address   Marriage Information- If applicable Marriage Date Family Address Street Address * Street Address Line 2 City * State/Region AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming * Enter Region Zip Code * Family Shipping Address Only enter Shipping Address if it is different from the Residence Address. Shipping Street Address Shipping Street Address Line 2 Shipping City Shipping State/Region AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Enter Region Shipping Zip Code Contact Home Phone ()-ext Enter International Number Familys Primary E-Mail Address * Familys Secondary E-Mail Address Opt Out of Agency E-Mailings Used only on a limited basis for important information Opt Out of Agency Mailings Mailings from us are extremely rare Password Please enter a password to use at a later time to access other forms on our website. Please write down and keep this password in a safe place. Family Login Password Password Already Set Change Password Confirm Password Password must be at least 8 characters with at least one uppercase letter, one lowercase letter, and one number. How did you learn about our agency? How did you hear about us? Google Search Yahoo! Search MSN Search Adoption.com Friend International Placing Agency Acquaintance Previous Client Adoptive Families Magazine/Guide Book Adoption Support Group/Conference Doctor Newspaper Counselor/Therapist Drive-By Building Sign Yellow Pages Church Radio Other *  Referral Source Details Categories Interested In Please select the categories which you are interested in at this time Domestic Adoption  International Adoption Embryo Adoption Foster Care Adoption Trans-Racial Adoption Home Study Services Other If you selected Other, Please Specify What brings you to our office? Briefly explain what brings you to our office for a consultation and what you hope to learn during our time together: If you have any Special Communication needs, then please explain: Consultation Time Preference Check all that apply. We will contact you via e-mail to set up an office appointment time. Day Time Appointment Friday Evening Appointment Phone Number for Scheduling Appointment, if we are unable to reach you via e-mail ()-ext Enter International Number We will most likely e-mail you for an appointment time Notes: Please indicate in Notes if you already have an appointment scheduled. Thanks! Additional Information Do you have a current adoption home study completed or started by another agency? Yes No * If yes, please explain Office Use Only Consultation Visit Date PC HS INTL DOM TRANS Initial Note:

Children: Gender and Age   How many children do you currently have? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15   Birth Date Gender     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female     Male Female

Thank you! We will contact you shortly to schedule your consultation visit.