Guest Author - Karen Ledbetter

Dear Adoptive Mother,
Thank you for taking time out of your busy day to fill out this questionnaire.
Your input is very important!

Please circle the responses that best describe you.
Age range
21-30 31-40 41-50 51+

Highest level of education:
high school some college associates bachelors graduate degree

Gross annual income level (do not include adoption subsidy)
Under $30,000 $31,000-$50,000 $51,000-$70,000 $70,000+

Ethnicity:
Caucasian Hispanic African-American Native American Asian Other:______

Family Information

Are you a single parent or a two parent family? ___Single ___Two-Parent

How many people are in your immediate family?____________

How many adopted children do you have?__________________

When did you finalize your first adoption?__________________

Do any of your adopted children have special needs? ___yes ___no

Does your child receive services for his or her special needs? ___yes ___no

Do you have a support system? ___yes ___no

Do you think of yourself as having a tie to a spiritual network? ___yes ___no

If yes, please describe what you think of as spiritual:







If yes, please also describe what you think of as a network:


.

To what extent are the following people supportive of you and your adoptive family?

1=never 2=sometimes 3=often

1. spouse or significant other 1 2 3
2. family 1 2 3
3. friends and neighbors 1 2 3
4. child’s teacher/school 1 2 3
5. adoption agency and workers 1 2 3
6. other adoptive parents 1 2 3
7. church members 1 2 3
8. pastor/priest/minister/rabbi/bishop/other clergy 1 2 3
9. counselor/therapist/psychiatrist/psychologist 1 2 3
10. child’s pediatrician/medical professional 1 2 3


Do you feel that your family……..

1. shares values and spiritual beliefs? ___yes ___no
2. has the strength to face the future? ___yes ___no
3. has a feeling of love and connection? ___yes ___no
4. spends enough quality time together? ___yes ___no
5. shares meaningful rituals and traditions? ___yes ___no
6. has enough structure each day? ___yes ___no
7. is flexible enough to change rules when needed? ___yes ___no
8. participates in lively discussions? ___yes ___no
9. celebrates special occasions in a meaningful way? ___yes ___no
10. frequently has fun together? ___yes ___no


Overall, how satisfied are you with the unity of your family since the adoption of your child(ren)? (Please circle one)

Very satisfied Somewhat satisfied Somewhat unsatisfied Very unsatisfied




What or who do you think has been the most helpful in supporting your adoptive family?




If you could suggest or create a support service for adoptive families, what would it be?



Email your completed survey to adoption@bellaonline.com. The Adoption Editor will forward all responses to Mrs. Bowles.