Adoption Disruption/Dissolution Survey for Parents

We are committed to protecting your privacy. Answers you give on this questionnaire will be kept

completely confidential. Your participation is valued greatly. If you have questions, comments or need assistance with this survey, please contact the MARE office at
(800) 589-6273 and we will gladly assist you.

*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.

ADOPTIVE PARENT(S) INFORMATION
	Adoptive Parent 1	Adoptive Parent 2
Gender	Male Female	Male Female
Date of Birth	MM/DD/YYYY format	MM/DD/YYYY format
Length of time married/partnered	years months	years months
Are you widowed?	Yes No	Yes No
If no longer married/partnered, length of time since divorce, separation, or death of spouse:	years months	years months
Education: Check all that apply.	Some high school High school graduate GED Vocational training Some college Associates Bachelors Some graduate school Master's degree MD/DO/PhD/JD/Other	Some high school High school graduate GED Vocational training Some college Associates Bachelors Some graduate school Master's degree MD/DO/PhD/JD/Other
Race/ethnicity: Check all that apply. (optional)	Black/African-American White/Caucasian Native American/American Indian Hispanic/Latino/Latina Asian American/Pacific Islander Chaldean/Other Arab-American Other	Black/African-American White/Caucasian Native American/American Indian Hispanic/Latino/Latina Asian American/Pacific Islander Chaldean/Other Arab-American Other
Current employment status: Check all that apply.	Employed full-time Employed part-time Homemaker/stay-at-home parent Unemployed, looking for work Unemployed, not looking for work Retired Student Disabled	Employed full-time Employed part-time Homemaker/stay-at-home parent Unemployed, looking for work Unemployed, not looking for work Retired Student Disabled
Occupation: If retired or not employed, describe previous occupation.
How long have you been an adoptive parent?	years months	years months
Prior to adopting this child, what parenting experience did you have? Check all that apply.	Biological Step Adoptive Foster Kin/Relatives Guardianship Other No Experience	Biological Step Adoptive Foster Kin/Relatives Guardianship Other No Experience
ADOPTIVE PARENT(S) INFORMATION – continued
How would you describe the area where you live?	Rural Small Town Suburban Urban	Rural Small Town Suburban Urban
Approximately how much is your household income?	Less than $10,000 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000 or above	Less than $10,000 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000 or above
Do you consider yourself religious/ spiritual?	Yes No	Yes No
How religious/spiritual do you consider yourself?	Extremely Very Moderately Somewhat Slightly	Extremely Very Moderately Somewhat Slightly
Currently, how many children are in your home?	# of children in the home	# of children in the home
How many of these children are:	Biological Adopted Step Kin/Relatives Foster	Biological Adopted Step Kin/Relatives Foster
CHILD’S INFORMATION
Child’s current name:	First:	Last:
Child’s previous name:	First:	Last:
Child’s date of birth:	MM/DD/YYYY format
Child’s gender:	Male Female
Child’s professional diagnosis or identified issues: Mark all that apply.	Physical disability or medical issues Mental or emotional/behavioral issues Learning disability or educational issues Substance or alcohol use
How long was this child in your home?
Was this child ever in residential treatment?	Yes No Do not know
If yes, what facility/agency/program?
If yes, when and for how long? Give dates if known.	Length of time: years months days Start Date: MM/DD/YYYY format End Date: MM/DD/YYYY format	Length of time: years months days Start Date: MM/DD/YYYY format End Date: MM/DD/YYYY format
Since starting the adoption process for THIS CHILD, how many foster, adoption, or post-adoption WORKERS did you and/or the child have?	1 2 3 4 5 or more Do not know
Have you experienced other adoption disruptions or dissolutions?	Yes No
	If yes, what year(s) did this happen?
Have you adopted another child since this disruption/dissolution?	Yes No
Would you consider adopting another child in the future?	Yes No
THE ADOPTION PROCESS
Whom did the worker meet with during the adoption homestudy process? Check all that apply.	Individually with you Individually with Parent 2 Both of you as a couple The adopted child Other child(ren) in your home
What type of preparation did YOU have BEFORE the adoption? Check all that apply.	Parent education classes Mandatory training One-on-one preparation with a worker Mentor family Online education Support group Other training Other
What type of preparation did the CHILD have BEFORE the adoption? Check all that apply.	Therapy Lifebook Good-bye visit with previous family/families Meeting with a worker Other Don’t know, was not told
How much did each of the following contribute to the disruption/dissolution?
There was a mismatch between the child and our family.
I/We couldn’t tolerate the child’s behaviors any more.
I/We believe we were misled about the child.
The training I/we received did not prepare us to deal with the child.
The child could not let go of the past and move forward.
I/We did not have the ability needed to cope with the child’s special needs.
I/We did not have support from our family or friends.
The agency did not provide needed services to support and sustain the placement.
The services offered were not effective or helpful.
There was a lack of support services in our community.
The child did not bond with our family.
I/We started having relationship/marital problems because of this child.
The child caused stress for our other children.
I/We felt fine caring for the child until he/she reached a particular [age] or [event].
Did maintaining contact with birth family contribute to the disruption/dissolution?
Were there other issues that contributed to this disruption/dissolution?	Yes No
If yes, what issues?
ADOPTION PLACEMENT INFORMATION
Please indicate which of the following describe the child’s behaviors:
Aggressiveness
Testing and control battles
Anger
Depression/sadness
Cheating
Lying
Stealing
Separation anxiety
Self-parenting or parenting siblings
Inappropriate sexual behavior
Problems forming relationships
Low self-esteem
Fire setting
Property destruction
Hoarding
Other (please describe other behaviors and how often they happened):


Please finish the following sentences with an ending that describes your thoughts about this disruption/dissolution. Feel free to add extra pages if necessary.
If I/we had it to do over, I/we would... It came down to a choice between ending the adoption or... I/We wish... If I/we could change one thing... When I/we adopted, I/we had hoped... Things really changed when... If you asked the child why his/her adoption ended, he/she would tell you... If asked, the worker would say the adoption ended because...
ADOPTIVE PLACEMENT INFORMATION - continued
This scale is intended to estimate your level of stress with the areas of your life listed below. Please circle one of the numbers (0-6) in front of and after each area listed. For each item listed down the center of the chart, please circle numbers for how stressed you felt BEFORE the child left your home and NOW, since the child left your home.
BEFORE— the child left your home		NOW— since the child left your home
	Relationship to spouse
	Relationship to children
	Relationship to other relatives
	Household management
	Financial situation
	Employment
	Education
	Recreation/leisure
	Social life
	Sex
	Religion
	Management of time
	Physical health
	Personal independence
	Satisfaction with life

How long was the child in the home before problems started?	years months days
Did you look for support services?	Yes No
If yes, what service(s)?
How long were there problems before you ASKED for help?	years months days
How long were there problems before you RECEIVED help?	years months days
Was there any service you wanted that you did not get?	Yes No
If yes, what service(s)?
Do you believe you were given all the information about the child’s history and needs, i.e., medical needs, history of abuse/neglect, mental health issues, etc.	Yes No
If no, what was missing?
What, if anything, do you believe could have been done to maintain this adoption?
ADOPTIVE PLACEMENT INFORMATION - continued
What expectations did you have of the SYSTEM that did not come true?
What expectations did you have of the CHILD that did not come true?
What expectations did you have of YOURSELF or YOUR SPOUSE that did not come true?
Please indicate your agreement or disagreement with the following statement: “We/I could not have done anything more than we/I did to maintain this adoption.”
To what extent do you believe worker turnover affected this adoption?
Adoption worker:
Therapist:

Did you contact the Subsidy Office to ask for help?	Yes No
If yes, what type of help were you looking for?

If yes, please indicate how satisfied you were with the Subsidy Office service:
Is there anything we have not asked you about the child or the disrupted/dissolved adoption that you would like to tell us about? If so, please use the space below and/or add extra pages if needed.