Register your Agency, Part 1
Please complete the form below to register your agency for only $29.99 per month/state.
First, tell us about the services you provide.
* Signifies a required field. |
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| Contact / Billing Information |
| * First Name |
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| * Last Name |
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| * Billing Address |
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| * City |
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| * State, Postal Code |
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| * State To Be Listed |
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| Multiple States? | Check here if you'd like register your agency
in more than one state.
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| * Country |
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| * Phone |
(
)
Ext.
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| Fax |
(
)
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| * E-Mail |
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*Password
(min. 5 characters) |
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| *Password (confirm) |
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| Agency Information |
| *
Agency Name or Individual Social Worker
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| * Physical Address |
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| * City |
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| * State |
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| * ZIP |
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*
Services Available
(please check all that apply)
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Home Study Agency
Domestic Adoption Agency
International Adoption Agency
Individual Social Worker |
| Agency: is
agency a licensed, not-for-profit Agency? |
Yes
No
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| Agency: has agency received accreditation for intercountry adoption under the Hague Convention? |
Yes
No
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| Agency: If Yes, who is the accrediting authority? |
COA: |
Yes
No
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| State of |
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| Other: |
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| Agency: If No, has agency received temporary accreditation for intercountry adoption under the Hague Convention? |
Yes
No
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| Agency: If Yes, who is the accrediting authority? | COA: |
Yes
No
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| State of |
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| Other: |
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Agency: If No, is agency supervised by a Hague-accredited Agency? |
Yes
No
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| Agency: If Yes, list supervising accredited agency: |
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| Individual
social worker: do you write home studies through an agency? |
Yes
No
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| Individual Social Worker: If Yes, list agency: |
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| Individual Social Worker: is the agency you write for a licensed, not-for-profit agency? |
Yes
No
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| Individual Social Worker: is the agency you write for either Hague-accredited, temporarily Hague-accredited, or supervised by a Hague-accredited agency for international adoptions? |
Yes
No
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| Home Study Fee |
$
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| Post Placement Fee |
$
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| Home Study Update
Fee |
$
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| Home Study Addendum
Fee |
$
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| Travel Fee |
$
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| What states are you licensed to perform home studies? |
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| In those states, list how long a home study is valid until an update is required. |
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| In those states, list number of post placement visits that are required. |
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| Do you service the entire state? If no, please indicate areas serviced. |
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| Have you performed home studies for international adoption? |
Yes
No
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| If yes, list all countries that you have successfully completed home studies for. |
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| If no, are you able to perform home studies for international adoptions? |
Yes
No
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| How many home studies did you (or your agency) complete last year? |
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| Other Comments |
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