Information
from family about living conditions and education
of the
adopted child
Family registration number in the
Center ______________________________________________
Names and last names of parents
___________________________________________________
Address________________________________________________________________________
Telephone
(E-mail)_______________________________________________________________
Name and last name of the child
before adoption_______________________________________
After adoption
_____________________________________________________________
date of
birth_______________________________________________________________
date and place
of adoption ___________________________________________________
Date of arrival in the receiving
country________________________________________________
Date of registration with consulate
of Ukraine__________________________________________
Information about physical
development of the child: height and weight changes, food. Motor system development.
Possible illnesses after arrival in the receiving country.
Information on mental condition of a
child his/her intellectual and verbal development. Favourite toys, books.
Relationship between the child and
his/her friends, neighbors, teachers (if the child attends classes).
Household conditions of the child
Significant events: changes m family
life, moving, travel etc.
Conclusion: general impressions of a
surveyor about the family and the child's environment (if the report is made by
a social worker)
Picture enclosed
Date of filling the form
Signature