Adoption Consent Form - Preparation Worksheet - Pennsylvania
PENNSYLVANIA ADOPTION-CONSENT INTAKE AND DRAFTING PACKET
DO NOT SIGN OR FILE
This packet records facts and questions for counsel. It does not consent to an
adoption, relinquish a right, transfer custody, authorize placement, waive
notice, approve contact, revoke an earlier act, or bind any person or authority.
1. Matter Control
| Item | Verified entry |
|---|---|
| Child's current name and any protected-name handling | [________________________________] |
| Child's date and place of birth | [________________________________] |
| Court, agency, or other authority, if known | [________________________________] |
| Case number, if assigned | [________________________________] |
| Proposed adoptive parent or parents | [________________________________] |
| Current caregiver or custodian | [________________________________] |
| Agency, facilitator, or other professional | [________________________________] |
| Counsel for each person | [________________________________] |
| Proposed signing or filing date | [__/__/____] |
| Immediate deadline or safety concern | [________________________________] |
2. Route and Proceeding Identification
Counsel must identify the actual route before drafting.
☐ Agency placement or custody route
☐ Direct placement route
☐ Stepparent or relative route
☐ Adult adoption route
☐ Existing child-protection, parentage, custody, guardianship, or termination matter
☐ Interstate, international, tribal, or federal overlay
☐ Route not yet determined
Counsel's route conclusion and supporting record: [________________________________]
3. Person and Status Register
Do not infer consent authority from a family label, absence, informal
agreement, genetic relationship, support history, or current physical custody.
| Person | Claimed relationship or role | Address or protected-contact status | Existing order or record | Counsel determination |
|---|---|---|---|---|
| [________] | [________] | [________] | [________] | [________] |
| [________] | [________] | [________] | [________] | [________] |
| [________] | [________] | [________] | [________] | [________] |
Record possible parents, legal parents, spouses, guardians, custodians,
agencies, representatives, the child, and any person whose status is disputed.
4. Child and Placement Record
| Issue | Information and supporting document |
|---|---|
| Current residence and caregiver | [________________________________] |
| Prior residences and placements | [________________________________] |
| Siblings and proposed continuing relationships | [________________________________] |
| Medical, developmental, educational, language, and accessibility needs | [________________________________] |
| Existing custody, contact, support, or protection orders | [________________________________] |
| Proposed placement and transition plan | [________________________________] |
| Interstate, international, or tribal connection | [________________________________] |
| Safety, confidentiality, or protected-address concern | [________________________________] |
5. Current-Law and Form Register
Counsel must complete each applicable row from current official sources and the
actual case record. This packet states no answer.
| Question | Current official authority, form, or order | Operative text or instruction | Applied result | Checked on |
|---|---|---|---|---|
| Persons whose consent or other act is required | [________] | [________] | [________] | [__/__/____] |
| Exceptions, prior orders, or court findings | [________] | [________] | [________] | [__/__/____] |
| Child's own consent, participation, or representation | [________] | [________] | [________] | [__/__/____] |
| Required document type and contents | [________] | [________] | [________] | [__/__/____] |
| Language, interpretation, counseling, or advisement | [________] | [________] | [________] | [__/__/____] |
| Timing after birth or another event | [________] | [________] | [________] | [__/__/____] |
| Authorized signing, witnessing, acknowledgment, or supervision | [________] | [________] | [________] | [__/__/____] |
| Filing, delivery, notice, and copy requirements | [________] | [________] | [________] | [__/__/____] |
| Effectiveness and custody consequences | [________] | [________] | [________] | [__/__/____] |
| Withdrawal, revocation, challenge, and deadline | [________] | [________] | [________] | [__/__/____] |
| Contact agreement or communication terms | [________] | [________] | [________] | [__/__/____] |
| Interstate, international, tribal, and federal issues | [________] | [________] | [________] | [__/__/____] |
6. Signer Information and Capacity
| Item | Entry |
|---|---|
| Proposed signer's full legal name | [________________________________] |
| Date of birth | [__/__/____] |
| Address and safe-contact method | [________________________________] |
| Primary language and interpreter need | [________________________________] |
| Disability or communication accommodation | [________________________________] |
| Counsel or independent adviser | [________________________________] |
| Decision-support person requested | [________________________________] |
| Medication, health, coercion, threat, payment, or pressure concern | [________________________________] |
| Documents and explanations received | [________________________________] |
| Questions not yet answered | [________________________________] |
No person should sign an operative document prepared from this packet until
counsel confirms capacity, voluntariness, required advice, language access,
identity, and the authorized execution process.
7. Social, Medical, and Family Information
| Record | Source | Complete | Delivery or confidentiality instruction |
|---|---|---|---|
| Child medical and developmental history | [________] | ☐ | [________] |
| Family medical and genetic history | [________] | ☐ | [________] |
| Social and family history | [________] | ☐ | [________] |
| Prenatal, birth, and hospital record | [________] | ☐ | [________] |
| Existing evaluations and services | [________] | ☐ | [________] |
| Identity, contact, and privacy preferences | [________] | ☐ | [________] |
8. Payments, Expenses, and Promises
Record every payment, reimbursement, gift, service, housing arrangement,
transportation item, medical cost, legal fee, or other benefit. Do not classify
it as permitted or prohibited in this packet.
| Date | Payer | Recipient | Amount or value | Purpose | Document | Counsel conclusion |
|---|---|---|---|---|---|---|
| [________] | [________] | [________] | $[________] | [________] | [________] | [________] |
| [________] | [________] | [________] | $[________] | [________] | [________] | [________] |
9. Drafting Instructions
| Operative document issue | Counsel instruction |
|---|---|
| Exact document type and parties | [________________________________] |
| Required findings, statements, warnings, or certifications | [________________________________] |
| Child and signer identifiers or protected information | [________________________________] |
| Placement or agency identification | [________________________________] |
| Notice and copy recipients | [________________________________] |
| Execution date, time, place, and authorized official | [________________________________] |
| Filing or delivery method | [________________________________] |
| Case-specific withdrawal or challenge instructions | [________________________________] |
| Contact or communication document, if separate | [________________________________] |
| Translation, interpreter, accessibility, and retention | [________________________________] |
Do not add commercial-contract terms such as warranties, default, damages,
fees, indemnity, liability limits, arbitration, jury waiver, force majeure,
assignment, integration, severability, counterparts, or electronic-signature
language unless counsel identifies a lawful and necessary use in a separate
document.
10. Final Gate
☐ The correct adoption and placement route is established.
☐ Every person and status question is resolved from supporting records.
☐ Current official law, forms, instructions, and case orders were checked.
☐ Required advice, counseling, interpretation, accommodations, and copies are arranged.
☐ Timing and execution are calendared from the verified authority.
☐ Interstate, international, tribal, and federal issues are resolved.
☐ Counsel prepared the separate operative documents.
☐ This intake packet will not be signed, notarized, filed, or served.
Reviewing Pennsylvania adoption counsel: [________________________________]
Review date: [__/__/____]
Separate operative document reference: [________________________________]
About this template
- Last updated
- August 24, 2026
- Last reviewed
- August 24, 2026
- Jurisdiction
- Pennsylvania
- Category
- Family Law
Family law covers the paperwork that shapes divorce, custody, child support, adoption, guardianship, and other family matters. These filings are emotional and high-stakes, and they also have to meet strict procedural rules for service, financial disclosure, and parenting plans. Clean, accurate paperwork keeps the focus on getting a workable outcome for the family instead of getting derailed by technical problems that delay hearings or force amended filings.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on August 24, 2026.
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