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Address:

Home Phone:*

Email:*

Child(ren)'s Name(s):
(Separate multiple entries by
using ',' commas)

Date(s) of Birth:

Birth Countr(ies):

Client's Relationship(s) to Child(ren):

Age(s) at time of Adoption:

Type(s) of Adoption (Check all that apply):

Domestic Adoption

International Adoption

Open Adoption

Closed Adoption

Single Parent Adoption

Gay/Lesbian Adoption

Please Check Off Areas of Interest:

Pre-Agency Selection Consultation

Pre-Adoption Consultation

Post-Adoption Consultation

Separation/Divorce Consultation

Homeland Tours

Group Traning/Seminars

Advanced Clinical Training

Psychotherapy Services

Adoption Coaching

Specific questions/concerns/areas of interest you would like to address during consultation:

Preferred time for consultation:
(Mon - Fri 8 am - 6 pm EST )

Preferred method for consultation:

Any other information you believe would be useful:

I understand that all Consultations offerred by OnTrack Adoption Associates constitute an opinion based on limited information provided at the time of service. Consultations by no means constitute a clinical impression nor a diagnostic evaluation of any client. Consultations are not psychotherapy and thus do not provide psychological treatment to the child or family.

I also understand that the consulting clinician cannot provide a diagnosis nor future prognosis for the child(ren) being discussed.

I understand and agree to these terms.