If you have a prior surgery or medical diagnosis, please list the dates. If this is ongoing, please describe how this diagnosis affects your everyday life.

If you have a prior surgery or medical diagnosis, please list the dates. If this is ongoing, please describe how this diagnosis affects your everyday life.

If you have ever had a mental health diagnosis, please describe what the diagnosis was and include the dates of diagnosis. Please also indicate if you saw a mental health professional during this time.

If you have ever had a mental health diagnosis, please describe what the diagnosis was and include the dates of diagnosis. Please also indicate if you saw a mental health professional during this time.

If you have ever used prescription medication, please indicate the medication name, dosage, time used, and reason this medication was used.

If you have ever used prescription medication, please indicate the medication name, dosage, time used, and reason this medication was used.

If you have ever had allegations, charges, or convictions of any criminal or child abuse, please indicate below. Please include the date, original charge, disposition of the charge, and how the charge was resolved. (Some countries may require that documentation be provided before the eligibility check will be completed)

If you have ever had allegations, charges, or convictions of any criminal or child abuse, please indicate below. Please include the date, original charge, disposition of the charge, and how the charge was resolved. (Some countries may require that documentation be provided before the eligibility check will be completed)

Please include anything that your family owns that has value (including cars, appliances, jewelry, homes, books, etc.)

Please add up the debt that your family has including loans, mortgages, credit card debt, etc.

Please subtract your liabilities from your assets and put the total amount below.

Please be aware that by submitting this Eligibility Check, you are stating that all this information is true to the best of your knowledge. This information will be required to have documented proof in the dossier process. If any of this information is difference than indicated in this form, the country and central authority may reject your application for adoption. Our management team cannot guarantee that your family will be approved for adoption. The country and central authority will approve your application for adoption once the entire dossier is sent to the country and reviewed. This Eligibility Check is meant to determine whether the country will consider your application for adoption. Please sign your name below to indicate that you have read and agree to this disclaimer.