Search Services Request Form

All fields are required.

Date of Request:

10/23/2021

Requester:

Street Address:

City:

State:

Zip Code:

E-mail:

Date of Birth:

mm/dd/yyyy

Home Phone:

###-###-#### or (###) ###-####

Cell Phone:

###-###-#### or (###) ###-####

Preferred Method of Contact:

Home Phone
Cell Phone
Email

REFERRAL BY:
Birthparent (adoptee aged 21 or older)
Adoptee (18 years of age or over)
Adoptive Parent (adoptee under age 18)
Legal Guardian of Adoptee (adoptee under age 18)
Descendant of a deceased adoptee
Grandparent (if birth parent consents, is incapacitated or deceased)
Birth sibling of an adoptee (21 years or older)
(other legislation requirements specify authorized sibling requests)
Other
If 'Other', please specify:

SERVICES REQUESTED:

Education (ACT 101, Search Service Options and Procedure information)
Search Information
Birthparent Requesting Update on Child
Update Information in File
Appointment for Adoptee to see Case Manager
Search & Reunion Services

Additional Comments:

FEES:
Non-identifying Search	$150.00
Identifying (Full Search Services)	$300.00
Reunion/ Miscellaneous Services	$49.00 per hour casework counseling services