Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">At this time our Private Infant Adoption Program is closed. If you would like to be put on a waiting list, let us know below in the questions and concerns section.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label>Basic Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Thank you for taking the time to complete this form. Please answer questions completely and honestly.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_A"><i class="fa fa-font"></i><label class="er_fld_label required">First Name (Parent A)</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_A"><i class="fa fa-font"></i><label class="er_fld_label required">Last Name (Parent A)</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="FH_Gender_A"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Sex (Parent A)</label><select name="CST_30" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="FH_DOB_A"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth (Parent A)</label><input class="cst_datepicker er_fld_required" name="CST_48" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail"><i class="fa fa-font"></i><label class="er_fld_label required">Email Address (Parent A)</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Mobile"><i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number (Parent A)</label><input name="CST_4" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_B"><i class="fa fa-font"></i><label class="er_fld_label">Partner/Spouse First Name (Parent B)</label><input name="CST_5" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_B"><i class="fa fa-font"></i><label class="er_fld_label">Partner/Spouse Last Name (Parent B)</label><input name="CST_6" type="text"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;" map_to="FH_Gender_B"><i class="fa fa-caret-down"></i><label class="er_fld_label">Sex (Parent B)</label><select name="CST_31"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option></select></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="FH_DOB_B"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth (Parent B)</label><input class="cst_datepicker" name="CST_49" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail_2"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address (Parent B)</label><input name="CST_33" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Mobile_B"> <i class="fa fa-font"></i><label class="er_fld_label">Phone Number (Parent B)</label><input name="CST_34" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_MaritalStatus"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Relationship Status</label><select name="CST_7" class="er_fld_required"><option value="Single " selected="">Single </option><option value="Dating/Engaged">Dating/Engaged</option><option value="Married">Married</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="FH_Years_Married"><i class="fa fa-caret-down"></i><label class="er_fld_label">If married, for how long? </label><select name="CST_8"><option value="N/A" selected="">N/A</option><option value="Less than 2 years">Less than 2 years</option><option value="2 years (Foster Care/Adoption Minimum Requirement for Married Couples)">2 years (Foster Care/Adoption Minimum Requirement for Married Couples)</option><option value="3 years (PIA Minimum Requirement for Married Couples)">3 years (PIA Minimum Requirement for Married Couples)</option><option value="4+ years">4+ years</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Household Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_1"><i class="fa fa-font"></i><label class="er_fld_label required">Street Address</label><input name="CST_9" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Apartment # (if applicable) </label><input name="CST_10" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_City"><i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_State"><i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_12" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_number" draggable="false" style="width: 20%;" map_to="FH_Address_Zip"><i class="fa fa-hashtag"></i><label class="er_fld_label required">Zip Code </label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_County"> <i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_14" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;" map_to="Location"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Which TBHC Office are you closest to? </label><select name="CST_16" class="er_fld_required"><option value=""></option><option value="Bedford">Bedford</option><option value="Lufkin">Lufkin</option><option value="Permian Basin (Odessa)">Permian Basin (Odessa)</option><option value="Tyler">Tyler</option><option value="Waxahachie">Waxahachie</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Background Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="FH_ReferralSource"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How did you find out about TBHC? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Google (TBHC Website)">Google (TBHC Website)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Facebook">Facebook</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Instagram">Instagram</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="I went to a Foster Care & Adoption Event ">I went to a Foster Care & Adoption Event </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="I'm connected with a TBHC Foster/Adopt family ">I'm connected with a TBHC Foster/Adopt family </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Family Member or Friend ">Family Member or Friend </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="My Church">My Church</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="I've attended a Joint Information Meeting (JIM)">I've attended a Joint Information Meeting (JIM)</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="CPS/DFPS/OCOK ">CPS/DFPS/OCOK </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_19" value="Hope Local or Brave Event">Hope Local or Brave Event</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_19" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_19_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_ReferredByName"> <i class="fa fa-font"></i><label class="er_fld_label required">Please name the person, event, or church who referred you if applicable</label><input name="CST_21" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_selected" style="white-space: normal; width: 50%;" draggable="false" map_to="none"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you attend a church in your area? (TBHC requests a reference from a church leader/pastor.)</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="No">No</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="No, but I have recently moved/changed churches and am looking for a new church">No, but I have recently moved/changed churches and am looking for a new church</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="Yes, and they have a foster care & adoption ministry">Yes, and they have a foster care & adoption ministry</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_17" value="Yes, but they don't have a foster care & adoption ministry">Yes, but they don't have a foster care & adoption ministry</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_17" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_17_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Church"> <i class="fa fa-font"></i><label class="er_fld_label">What is the name of your Church? (if applicable)</label><input name="CST_18" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Does your church have a foster care and adoption ministry?</label><select name="CST_47"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unsure">Unsure</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Our family recruiter will promptly reach out to your family with additional information Due to our emails consistently ending up in junk/spam folders, we have been reaching out by call and/or text message to ensure you have received a follow up. If your family would prefer not be reached by call or text, please let us know by using the text box below. We're looking forward to meeting your family very soon!</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"><i class="fa fa-paragraph"></i><label class="er_fld_label required">Questions or Concerns?</label><textarea name="CST_26" style="width:100%;" class="er_fld_required"></textarea></li></ul>
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