Adoption Disruption/Dissolution Survey for Parents

Adoption Disruption/Dissolution Survey for Adoption Professionals Per DHS Adoption Policy, adoption workers must notify MARE of any disruption or dissolution within 10 working days. This survey must be submitted to MARE within 30 calendar days of receipt. More information may be found in the adoption services manual, ADM 730. I nformation provided in this survey will be kept completely confidential. Data gathered will be reported only in an overall summary. Your professional feedback is valued greatly. You may also download the PDF version of this survey by clicking here. *Required Fields are marked with an asterisk ()**
REGARDING:
Child's First Name: *
Child's Last Name: *
Child's Date of Birth: *	(MM/DD/YYYY)

Name of Adoption Specialist completing this survey: *
Phone Number: *	example: (313-555-5555)
Email Address: *
Name of child’s adoption agency:
Name of family’s adoption agency:
DEFINITIONS *Disrupted Adoption:* Adoptive placement ended after the Order Placing Child and prior to finalization. Dissolved Adoption: Parental Rights of adoptive parent[s] were terminated after finalization. Based on the above definitions, did this child’s adoption Disrupt or Dissolve ? *
DISRUPTED / DISSOLVED ADOPTIVE FAMILY DEMOGRAPHICS Current ZIP Code: Example: (48127) ZIP Code at time of adoption: Example: (48127) Current Family Situation: One-Parent Family Two-Parent Family Family household income: Current or Last Known $15,000 - 17,499 $17,500 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 75,999 $76,000 + Subsidy Received: [check all that apply] No Subsidy Medical Subsidy Support Subsidy SSI HOUSEHOLD INFORMATION At the time of disruption / dissolution: Total # of children in the family [include adult & minor children]: How many were living in the home: Total # of biological & step-children: Total # of foster children who were living in the home: Total # of adopted children [include child experiencing disruption / dissolution]: Total # of other children who were living in the home: [grandchildren, nieces, nephews, etc.] Has the family experienced any prior disruptions or dissolutions? Yes No I Don't Know Was this adoption an immediate confirmation? Yes No If No, # of months of supervision: How many years of parenting experience did the parent(s) have at the time of the disruption/dissolution:? Biological-Parent Step-Parent Foster Parent Adoptive Parent CHILD SPECIFIC INFORMATION Child’s Current First Name: * Child's Current Last Name: * Child's Previous First Name: * Child’s Previous Last Name: * Child’s DHS Recipient ID: Child’s Date of Birth: * MM/DD/YYYY Child’s Gender: Male Female Child’s Race: [check all that apply] Black / African-American White / Caucasian Hispanic / Latino / Latina Asian American / Pacific Islander Chaldean / Arab - American Other Date of child’s initial removal from birth family: MM/DD/YYYY Original Permanent Custody Date: MM/DD/YYYY Date of Order Placing Child After Consent: MM/DD/YYYY Date of Order of Adoption: MM/DD/YYYY Date of Disruption [ex parté] or Dissolution [Order Terminating Parental Rights]: MM/DD/YYYY Type of adoptive family: [check one]: Foster Parent Adoption Recruited Family Adoption Relative/Kinship Adoption Other: [specify] Was child ever photolisted with MARE? Yes , MARE # C No Do not know Were birth siblings of this adopted child also adopted by this family? None All Some As a result of this disruption/dissolution, did any of this child's birth siblings remain with this family? Yes, birth siblings remained with this family No , there weren't other birth sibs in this placement OR No, the adoptive placement for this child's birth siblings also disrupted/dissolved with this family. Professional Diagnosis or Identified Issues: [check all that apply & describe specifically] Physical Disability or Medical Issues: Mental / Emotional / Behavioral Issues: Learning Disability or Education Issues: Other: Was child ever placed in residential treatment? Yes No Do not know If Yes: Facility / Agency / Program: # of Months Facility / Agency / Program: # of Months Child’s living arrangement after disruption / dissolution: Foster Home Relative Home Residential Facility Other - Was there a case worker change during placement? Yes No Supervision? Yes No If Yes, how many workers? Reason for change(s): If Yes, how many workers? Reason for change(s): Total number of foster care placements that this child experienced since coming into care:
ADOPTION PARENT[S] INFORMATION
	Adoptive Parent 1	Adoptive Parent 2
Name:	*
Current Address:	*
Gender	Female Male	Female Male
Date of Birth:	MM/DD/YYYY	MM/DD/YYYY
If married / partnered, anniversary date:	MM/DD/YYYY	MM/DD/YYYY
Zip Code:	Example: (48127-3403)	Example: (48127-3403)
State:
If no longer married / partnered, divorce / separation date:	MM/DD/YYYY	MM/DD/YYYY
Occupation:
Level of education:	Some HS HS GED Vocational Training Some College Associates Bachelor's Degree MD/DO/PhD/JD	Some HS HS GED Vocational Training Some College Associates Bachelor's Degree MD/DO/PhD/JD
Parent’s race: [check all that apply]	Black / African-American White / Caucasian Native American / American Indian Hispanic / Latino / Latina Asian American / Pacific Islander Chaldean / Arab - American Other -	Black / African-American White / Caucasian Native American / American Indian Hispanic / Latino / Latina Asian American / Pacific Islander Chaldean / Arab - American Other -
PRE AND POST ADOPTION SERVICES & TRAINING ISSUES
Did the adoptive family receive pre-adoption training?	Yes No
If Yes, what type of training was it? [one-on-one, small group, large group, etc.]
Name of the training program[s]?
Who provided the training?
Number of hours of training received:
If No, why not?
Did the adoptive family utilize any post-adoption services?	Yes No
If Yes, describe type of service[s]:
Service provider[s]:
Dates of service[s]:
Who was served:
If No, why not?
Were there other post-adopt services available but NOT utilized?	Yes No
If Yes, describe:
Were other post-adopt services needed but unavailable?	Yes No
If Yes, describe the service[s] that may have helped prevent this disruption / dissolution, who may have been served, and why the service[s] may have helped:

REASONS FOR THE DISRUPTION / DISSOLUTION
Family’s stated reasons for this disruption / dissolution:
Your perception of the reasons for this disruption / dissolution. Please note whether Protective Services was involved in this case or whether this was a voluntary release:
Additional comments, concerns, suggestions that may assist us in studying disruptions & dissolutions:

Michigan Adoption Resource Exchange
Po Box 980789
Ypsilanti, MI 48197