Please fill out this eligibility application to access resources from Adoption Mosaic.

How were you referred to Adoption Mosaic? *

Oregon Department of Human Resources (ODHS)

Oregon Post Adoption Resource Center

Adoption Agency

Other

If you answered "Adoption Agency" or "Other", please specify.

Identification of type of Post Permanency: (check all that apply) *

Post adoptive families whose adoption of a child or children through Oregon Department of Human Services (ODHS) has been designated or finalized, or a family who resides in Oregon whose adoption of a child or children through another public child welfare or private agency has been designated or finalized

Post guardianship families whose guardianship of a child or children through ODHS or a family that resides in Oregon whose guardianship through another public child welfare agency has been established or approved to proceed

Pre-Adoptive Family currently working with a public child welfare adoption agency

Relationship with child(ren): (check all that apply) *

Personal Information

Parent 1 First Name: *

Parent 1 Last Name: *

Phone: *

Email: *

Mailing Address: *

Apartment Number:

City: *

State: *

Postal Code: *

Partner or Spouse's First Name:

Partner or Spouse's Last Name:

How many caregivers (adults) are in your household? *

How many children are in your household? *

Do you have any children (post-adoptive or post-guardianship)? *

Yes

Child #1 Information

Child #1 Full Name: *

Child #1 Age: *

If you chose "Other" for child #1 gender, please explain.

Primary race/culture identification of child #1: *

Do you have more children to list (post-adoptive or post-guardianship)? *

Yes

Child #2 Information

Child #2 Full Name: *

Child #2 Age: *

If you chose "Other" for child #2 gender, please explain.

Primary race/culture identification of child #2: *

Do you have additional children to add (post-adoptive or post-guardianship)? *

Yes

Child #3 Information

Child #3 Full Name: *

Child #3 Age: *

If you chose "Other" for child #3 gender, please explain.

Primary race/culture identification of child #3: *

Do you have any more children to add (post-adoptive or post-guardianship)? *

Yes

Additional Children

List all additional children's full names. *

List all additional children's ages (next to name): *

What is their gender identification? (Male, Female, Non-Binary, Trans, or Other)

Please indicate name beside gender identification. If "Other", please explain. *

What is their primary race/culture? (White, Black/African American, American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, Latino/Hispanic)

Please indicate name beside race/culture. *

Primary reason for your family engaging in services: (write in your answer) *