Family Application Packet

    Adoption Support Groups

    Intake Packet

    Thank you for your interest in the AdoptionWorks Post Adoption support groups! At AdoptionWorks, we provide a safe and loving environment where families find support and encouragement, and children and Teens can connect with others who are adopted.

    Please read and complete the enclosed forms, ensuring all forms are signed and dated. You may send your completed application to RUTH BALDERAS, via e-mail or to the address listed on the cover page.

    Family QuestionnaireAttendance PolicyAuthorization for Release of Information (if needed)Wellness PolicyAdult FormChild FormFamily Agreement FormTeen FormRights and Exceptions to PrivacyPermission FormRelease of Information for Support Group DirectoryNon- Subpoena Contract for Support Groups Adoptee RightsRules for SafetyScheduleIntake Packet Checklist

    AdoptionWorks Schedule

    AdoptionWorks will begin at 7:00 p.m. each night in the large room (by the kitchen). We will have weekly announcements about the childrens’ accomplishments and tee up session with group games

    Groups will run from 7:00 to 8:00 p.m. each Thursday for 8 weeks

    Group participants will be released by age groups to go to their rooms, followed by the adults. We will meet back in the large room no later than 7:45 p.m. and close out with individual family activities.

    Please see the list of topics below for the upcoming session. We are looking forward to the groups!

    Date Topic
    Week 1 My Adoption Story
    Week 2 Grief and Loss in Adoption
    Week 3 Bullying and Teasing
    Week 4 Anger
    Week 5 Identity
    Week 6 Worries and Fears
    Week 7 Trust and Forgiveness
    Week 8 Putting It All Together

    Family Orientation Questionnaire

    (Please fill in the following tables)

    Please list all participating family members, including self (adults, Teens, and children)

    Family History

    Questions about the Adoptee(s): If more room needed, please list on back.

    ATTENDANCE POLICY

    You and your family have been granted a scholarship to our AdoptionWorks Groups Program. We look forward to seeing you at each meeting and we are asking you to commit to this 8 week session.

    • Please remember to RSVP prior to each session so that we may plan activities and staff our groups accordingly. To RSVP for group, please contact RUTH BALDERAS at 972.960.9981 EXT. 119 or email her at rbalderas@christian-works.org. She will send out an email for you to response every week.
    • If at any time, you and your family will miss a session, please advise 2 days in advance. Obviously, if illness plays a role notify us as soon as possible.
    • During the 8-week session, if your child becomes sick or shows symptoms of illness, please refer to our Wellness Guidelines.
    • In the event your family misses 2 or more sessions without notifying the center and Family Development Specialist, you will be asked to forfeit your place so that others can be served.

    We look forward to getting to know you and your family. Please do not hesitate to contact us with any questions or concerns, we want to help in any way we can.

    THE AdopteeS BILL OF RIGHTS

    Author Unknown

    • We have the right to dignity and respect.
    • We have the right to know we are adopted.
    • We have the right to possess our original birth certificate.
    • We have the right to possess all of our adoption records.
    • We have the right to full knowledge of our origins, ethnic and religious background, our original name and any pertinent medical and social details.
    • We have the right to updated medical and social history of our birthparents.
    • We have the right to personal contacts with each of our birth families, as all other humans.
    • We have the right to live without guilt toward any set of parents.
    • We have the right to treat and love both sets of parents as one family.
    • We have the right and obligation to show our feelings.
    • We have the right to become whole and complete people.
    • We have a right and obligation not to violate the dignity of all people involved in the adoption triad and to carry our message to all adopted children who still suffer.

    AUTHORIZATION FOR RELEASE OF INFORMATION

    If you want a staff member of AdoptionWorks to speak to another professional or anyone else about any of your family members, please complete this form, sign it with a witness, and have the witness sign and date. Complete a separate form for each child/Teen or organization to whom you authorize a release of information.

    I authorize the staff of AdoptionWorks to release information to:

    ADOPTIONWORKS WELLNESS POLICY

    In order to protect the well-being and health of all our AdoptionWorks families and the AdoptionWorks staff, we ask that family members not attend sessions when they:

    1. are running a fever
    2. suffering with a hacking cough or serious, contagious respiratory condition
    3. experiencing a sore throat
    4. displaying flu-like symptoms
    5. or in the beginning stages of a possible illness.

    If a child, Teen or adult family member cannot attend the AdoptionWorks session due to an illness, please let us know.
    We ask that you help to protect all our AdoptionWorks family members and staff while here for a session by:

    1. Observing such sanitary procedures as washing your hands. Hand sanitizing products are made available by AdoptionWorks in every room. If you don’t see any available hand sanitizer, ask a staff member.
    2. If children have an open wound, please make sure it is covered.
    3. Use the available face tissues in the waiting room and counseling rooms. If you don’t see a box, ask a staff member.
    4. If you cough or sneeze, cover your mouth and nose with the inside of your elbow or tissue.
    5. Report any unsanitary conditions to staff members.

    COVID Protocols

    To protect our employees and clients, as well as our community, ChristianWorks asks everyone who enters our office

    to abide by the following protocols:

    1. Clients and employees who have been fully vaccinated may choose not wear a mask while in our offices.
    2. All clients who enter our office must sign in at the front desk. By signing in, you agree to remain onsite only if you have not tested positive for COVID in the last 10 days, if you have not had any symptoms of COVID in the last 24 hours, or if you have not been exposed in the last 14 days to someone else who tested positive for COVID.

    ChristianWorks will continue to follow the recommendations set in place by the CDC.

    Adult Form

    Child Form

    FAMILY AGREEMENT FORM

    Before completing and signing this form, please read and discuss with the adults, children and Teens who want to participate at AdoptionWorks.

    1. We understand that AdoptionWorks provides support groups, not therapy or counseling.
    2. We understand that although we are not paying for the services of AdoptionWorks a generous donor is. Therefore, we know that someone is investing their hard earned dollars in our family and our welfare. Knowing that we are basically on a scholarship, paid by others, we agree to attend our group regularly. If we miss more than two consecutive sessions, except for illness or crisis, we may be dropped. We agree to call when we are unable to attend our group.
    3. We agree that children or Teen(s) must always be accompanied and supervised by a parent or another adult for every group meeting. We agree to always have a parent or another adult remain at AdoptionWorks while the child or Teen is in a group. We understand the adult has the option of participating in the adult support group.
    4. We understand that AdoptionWorks groups is designed for Adoptees only. Siblings, friends, and/or extended family members cannot attend group sessions.
    5. We understand that while children or Teens are in the same room with parents/guardians, that the parents/guardians are responsible for their children’s or Teen’s behavior and actions, not the staff. Staff and group facilitators will be responsible for children or Teens only when they are in their private group sessions away from parents/guardians.
    6. We have read and understand the Family Agreement Form. We have discussed this information and agree to abide by the guidelines of AdoptionWorks.

    Teen APPLICATION FORM

    RULES FOR SAFETY

    AdoptionWorks has nine rules developed to ensure the physical and emotional safety of the children and families.

    1. Stop Rule: “Stop and I mean it.” When someone is doing something that feels unsafe to anyone, that child/Teen needs to stop the activity immediately. If someone feels unsafe, it is his or her right to use their words to ask someone to “Stop.”
    2. Throwing Rule:

      Objects may not be thrown anywhere at AdoptionWorks.

    3. Put-Down Rule: No hurting other people’s feelings by making fun of them, name calling, ignoring, or put-downs. Respect each other and self.
    4. Hitting Rule: Children/Teens may hit the pillows or stuffed animals, but may not hit another person.
    5. Adult Rule: Children/Teens must be with an adult at all times while at AdoptionWorks. They may not leave the building unless accompanied by an adult.
    6. Blood Rule: Children/Teens are instructed not to touch blood. In the event that bleeding occurs, children/Teens are to tell an adult who will clean up the spill.
    7. Privacy Rule: What is said at AdoptionWorks is private and confidential, and stays here (exceptions are state-required reporting laws). It should not be posted on social media or discussed outside of group.
    8. I Pass Rule: Children/Teens can always “pass” if they do not want to talk.
    9. Listening Rule: We respectfully listen to each other, being considerate enough to allow everyone to have an opportunity to talk, if they so choose.

    Because we want to create the least restrictive environment possible, we explain these rules in three steps to smaller children:

    1. Stick together
    2. No hurts
    3. Have fun!

    YOUR RIGHTS TO PRIVACY AND EXCEPTIONS TO PRIVACY

    Our work with you and your family at ChristianWorks for Children is confidential. Information shared with the staff, volunteers and other participants is private. Your rights to privacy will be strictly maintained. There are, however, some important exceptions to privacy which are explained on the back.

    Please read the seven exceptions to privacy on the back before signing below.

    In signing this document, I acknowledge that I have had the opportunity to ask questions about ChristianWorks for Children’s Confidentiality Policy. I have read and understand the “Right to Privacy and Exceptions to Privacy” information. I fully understand and accept my rights to privacy and the exceptions to rights to privacy.

    SEVEN EXCEPTIONS TO PRIVACY

    Exception #1 Texas law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.
    Exception #2 If we learn that someone with whom we are working has a specific intent to bring harm to him/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.
    Exception #3 If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or Teen, we reserve the right to inform the parent.
    Exception #4 If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release, the court may nevertheless require compliance with the order.
    Exception #5 If we learn that someone participating in the program might commit a violent act, we may take steps to protect the intended victim against such danger or inform police, or both.
    Exception #6 The rights and exceptions to privacy apply to information disclosed in support groups. All group members are encouraged to keep such information confidential, but ChristianWorks for Children cannot guarantee they will do so.
    Exception #7 At times, ChristianWorks for Children uses case examples of children or Teens and their families in publishing articles, conducting professional training, community education, and in fund raising efforts. We may anonymously refer to your situation in those circumstances. Your child, Teen or family’s complete name will never be used without your specific written approval.

    AUTHORIZATION TO RELEASE INFORMATION
    ADOPTIONWORKS SUPPORT GROUP DIRECTORY

    An email written to members of the AdoptionWorks groups containing my contant information in order to maintain connections with the other particpants in the group once group ends.

    PERMISSION FORM

    To communicate ChristianWorks for Children mission and message we often want to use quotations, stories, artwork and other artistic expressions of the children and Teens for display boards, brochures, newsletters, lectures or training. The last name and detailed information about the child or Teen are not spoken or printed. Before we use any information, we will inform you and give you a copy, if requested.
    For confidentiality purposes, particularly pertaining to sensitive first family dynamics, we respect your privacy at all times.

    We give our permission to the above uses of pictures, artwork, quotations, stories.
    We give our permission with these exceptions:
    We do NOT give our permission to any of the above.

    Non-Subpoena Contract for Adoption Works Support Groups

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    ChristianWorks for Children is a 501(c)(3) non-profit — EIN: 75-1246028.
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