1-         Please check the entry that most closely matches your current status:             (Required items are marked with an *)
* Status:	Please select an item from the list below: Birth parent Adoptive parent Foster parent or fost-adopt parent Interested in being an adoptive parent Adopted person Counselor/Social worker Mental Health Practitioner Physician/Pediatrician Adolescent/Yound adult adoptee Support group participant Support group leader/organizer Person interested in adoptive issues Professional in adoption related work Other   * Zip Code:
How did  you hear about us?
2 -       Please fill out the following as completely as possible.  This information will            be critical in understanding who is in need of adoption services.   Again, we            assure you that any information you share will remain confidential.
Please specify your:
* Gender:	Select One Female Male
* Primary Race:
* Language:
* Cultural Background
* Age group:	Select One Under 18 18 to 24 25 to 35 36 to 46 47 to 57 58 to 65 Over 65
* Marital Status:	Select One Single Married Divorced Single Parent Widowed Alternative Relationship Other
* List your current or anticipated needs: (At least one item must be checked)
	General information for persons impacted by adoption Placing a child for adoption Open adoption Understanding the adoption process Parenting an adopted child Educational needs of an adopted child Adopting an older child Lifelong adoption issues Trans-racial/trans-cultural adoption International adoption process Behavioral/emotional concerns of an adopted child Adopted children with severe behavioral needs Clinical services Medical services Search and Reunion questions, etc. Peer support through mentoring Support groups for ADOPTIVE PARENTS Support groups for TEENS Support groups for BIRTH PARENTS Support groups for ADULT ADOPTEES     Other, please specify:
If you would like us to contact you directly regarding questions or concerns OR you wish to receive our ARCH Newsletter with periodic updates and event announcements, please share the OPTIONAL information below.
Name:
Daytime phone:
Evening phone:
Best time to call:
Address:
City and State:
Email address:
If you would like to receive the NJ ARCH Newsletter, what format?   Please select from the list below: Email US Mail
Thank you again for responding to this survey!             AND for helping us help others!