REFERENCE FORM

Dear Friend or Family Member,

Name of Person Completing this Reference Form

First Name

Last Name

Phone

(###)

###

####

Date Form Completed

YYYY

Name of the applicant(s) this form is being completed for:

How do you know the applicant(s) & how long have you known them?

How often are you in contact with the applicant(s)?

How would you describe their lifestyle, religious and/or cultural activities?

How would you describe their home in terms of stability, communication, support network, etc?

What words would you use to describe the applicant(s)?

Describe their interactions with children.

What special qualities will they bring to parenting?

Are you aware of any aspects of their background or personality that may interfere in the successful parenting of a child? If yes, please explain.

Do you have any doubts, reservations or hesitations about the applicant(s)?

Are there any other comments you would like to share?

Do you believe this will or will not make a good adoptive home? If yes, why?