Ny Adoption Form – Fill Out and Use This PDF

LDSS-0857 (Rev. 4/2011)

NOTE: If your application is rejected or if your application has not been acted upon within six months of filing by the completion of an adoption study, you may request a State administrative hearing. The hearing must be requested within 60 days after the date of rejection or failure to act.

NOTE: At such hearings, you will have the right to be represented by counsel or other representative to produce witnesses and other evidence on your behalf, to request the issuance of subpoenas, to cross-examine witnesses testifying against you, and to examine all evidence presented against you. If you wish to request a hearing, address your request to:

New York State Office of Children and Family Services

Special Hearings

52 Washington Street, Room 322 North

Rensselaer, New York 12144

NOTE: Social Services Law 424-a requires the authorized agency receiving this application to check with the New York State Register of Child Abuse and Maltreatment to determine whether an adoptive applicant and any person over 18 who resides in the home is the subject of an indicated report of child abuse and maltreatment.

NOTE: Social Services Law 378-a requires the authorized agency to complete a criminal history record check for a prospective adoptive parent or any other person over the age of 18 who is currently residing in the home.

NOTE: If you have acknowledged your willingness to adopt a handicapped or hard-to-place child, your name will be placed ion a Statewide computer file with the New York State Office of Children and Family Services only for the purpose of matching you with available children.

Note: Applicant should retain copy of application

LDSS-0857 (Rev. 4/2011)

CATAGORIES OF CHILD NEEDS

Medical/Physical Needs: This category includes children with specific medical/physical needs that may require an additional level of care beyond that normally given at the child’s age level. This category includes children that may display some of the following medical problems that range from acute to chronic and/or terminal illness: a child who experiences respiratory problems ranging from asthma to reactive airway disease or skin conditions that range from eczema to those that require surgical/medical intervention; children with physical disabilities that impair the use of vision, hearing and mobility; and children with neurological problems that range from seizure disorders to different levels of cerebral palsy. This section will include infants that require additional medical intervention as well as some children who have gastrointestinal medical needs, and children who experience a wide range of allergy conditions. Additionally, children with genetically inherited conditions such as Down’s syndrome, Fetal Alcohol Syndrome, Tourettes and sickle cell disease will be included in this section.

Educational/Learning Needs: This category includes children with educational/learning needs ranging from educational support to diagnosed learning disabilities. Examples will include visual/receptive/auditory processing difficulties, dyslexia and educational delays. In addition children may require special educational intervention.

Mental Health Needs: This category includes children with mental/emotional disorders ranging from experiencing acting-out behavioral and emotional problems to having been adjudicated Persons in Need of

Supervision (PINS), and Juvenile Delinquents. Further examples of mental health needs include those children exhibiting some of the following behaviors low-frustration tolerance, early sexual activity, sexually acting-out behavior, enuresis, encopresis, and cruelty to animals. Also included are children who exhibit these additional issues: resistance to adult authority, have difficulty with their peers, runaway behavior, school absence and or discipline issues, diagnosed attention problems including Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder, substance abuse sleep disorders, and theft and gang activity. Children who are physically aggressive, violent and destructive will be noted here.

Developmental Delay Needs: This category includes children whose developmental needs range from receptive/ expressive language, fine/gross motor skills, social adaptations, and self-help skills to those needing intensive assistance in self-help skills and assistance towards achieving independent living. Also included in this section are children who have temporary developmental delays or more permanent deficits.

EXPLANATION OF MILD, MODERATE AND SEVERE LEVELS

Mild:

Medical/Physical Needs: - Child has a condition(s) which require non-acute medical attention such as: visual or hearing impairments, allergies, asthma, controllable epilepsy or follow-up conditions which have been surgically corrected such as open heart surgery.

Educational/Learning Needs - Child is slightly behind in one or more subjects but attends regular school classes. Child may have some minor learning disabilities.

Mental Health Needs: - Child has a diagnosed condition that may mildly impair their ability to function such as an adjustment or attachments disorder. Child is generally emotionally stable but may be facing a situation (disruption, new foster home) that has created a temporary emotional stress and may be addressed. Child has or has had a problem controlling their behavior, usually associated with a specific incident such as a disruption.

Developmental Needs: - Child has a mild delay in development and may be receiving speech, occupational or physical therapy.

Moderate:

Medical/Physical Needs: - Child that has a moderate level of cerebral palsy, cleft defects which have not yet

been surgically treated, sickle cell disease if severe complications are not present, partial impairment of normal movement, diabetes, heart defects which can be repaired, spina bifida without the most severe complications.

Educational/Learning Needs: - Child is 2 to 3 years behind in subjects and receiving resource room help or other special tutoring aside from being in the regular classroom.

Mental Health Needs: - Children with one of the described conditions requiring on going intervention services and a higher level of supervision and or treatment. Child is experiencing emotionally related problems that may interfere with child’s school performance or interaction with others. Child has a history of acting out causing problems in school and in interpersonal relationships.

Developmental Needs: - Child needs assistance with skills of daily living. Child is receiving early intervention services for significant lags in speech, fine/gross motor skills.