1. (1) The following form is used for certification of the completion of any social counseling requested pursuant to T.C.A. §36-1-111(k)(2)(E) by the person who is surrendering the child for adoption, or who is executing a parental consent to unrelated persons, and must be filed with the surrender or parental consent before the surrender is executed before the court by the surrendering person, or before an order of guardianship is entered based upon any surrender, or parental consent to unrelated persons.
2. (2) This information shall be confidential and shall only be disclosed as provided by T.C.A. §§ 36-1-101 et seq.

3. (3) Form: CERTIFICATION OF COMPLETION OF SOCIAL COUNSELING RELATED TO ADOPTION PLACEMENT DECISION BY PARENT(S) TENNESSEE CODE ANNOTATED, § 36-1-111(l)(1) If the person surrendering the child(ren) for adoption has requested that the prospective adoptive parent(s) provide social counseling with regard to the decision of that person to surrender the child for adoption, this certification form must be completed by the person who provided such counseling before the surrender is executed. See, T.C.A. § 36-1-111(l)(1). NOTE: This form may be modified for use outside the State of Tennessee as long as the information requested is provided in the modified form. STATE OF TENNESSEE OR (________________) COUNTY OF _________________ Being duly sworn according to law, affiant would state:

   1. 1. I am _____________________________, (Name of Person Providing Social Counseling).
   2. 2. I was employed by, __________________________________ (Name of person(s) employing counselor to provide social counseling to surrendering person) to provide counseling to ___________________________________ (Name of person to whom was provided) regarding the social issues surrounding the decision by this person to place ____________________________________________ (Name(s) of the child(ren)) for adoption. This is to certify that during the course of social counseling the following issues have been addressed with ________________________________________ (Name of Birth/Legal Mother) ________________________________________, ( Name of Birth/Legal Father) ________________________________________ (Legal Guardian) who is before the Court (___), Warden (___), Officer (___) to surrender the child ____________________________________ for the purpose of adoption. (Name of Child) Options/Decisions Yes No To parent the child To place the child for the purpose of adoption Consequences of Decisions Exploration of Support Systems Family Friends Financial Employment/Education Child Support Public Assistance Birth Father/Mother Other (Identify) Grief/Loss Issues Related to Options for: Self Child Present Issues Future Issues Referral for further counseling Exploring Parenting Option Concept of Parenting Single Parenting Marriage Issues Present Future Financial/Employment/Child Support Medical Insurance Housing Education plan for self Child care Future life goals/plans Needs of the child Basic (food, clothing, housing) Special needs Physical safety Emotional Development Exploring Adoptive Placement Agency placement (DHS & private) Independent placement Plan of birth/legal mother or father Identification/information about birth parent, custodial person/guardian Background information Termination of parental rights Voluntary/involuntary Revocation of surrender Involvement in adoption process Selection of family Openness Meeting adoptive family Continued contact Direct placement/foster care placement Adoptive family preparation Agency selection of family Oral/physical presentation of child Pre-placement activity process Placement/post-placement services Finalization/court process Post legal adoption services Access of adoption records Contact veto registry SUMMARY OF COUNSELOR’S ASSESSMENT/RECOMMENDATION (If report is a separate document, please write “See attached” and attach report with this certification.) This the ____ day of _____________, 20_____ FURTHER, AFFIANT SAITH NOT. Please Print: ______________________________ Person Providing Social Counseling to Surrendering Person Title: ______________________________ Name of Agency, if Appropriate: ______________________________ Address: ______________________________ ______________________________ ______________________________ Signature: ______________________________ Sworn to and subscribed before me this _____ day of ____________, 20_______ ____________________________ NOTARY PUBLIC My Commission Expires:____________________ PARENT’S STATEMENT The above counseling issues have been discussed with me. As a result of the issues addressed during this process and in what I believe to be the best interest of my child _______________________________, I ______________________________, (Name of Child) (Birth/Legal Mother) _____________________________, or _________________________ have made the (Birth/Legal Father) (Legal Guardian) following plan for my child/ward. (Please Describe Your Decision/Plan): Please Print: _____________________________________________________ (Name of Parent/Legal Guardian) Signature of Parent/Legal Guardian: _________________________________ Date:________________________

Authority: T.C.A. §§ 4-5-201, et seq., 36-1-111(k)(l)(1)(m) and (o), 36-1-117(g), 36-1-125, and 36-1-141; Public Chapter 532 (1995); and Executive Order #6, January 12, 1996. Administrative History: Original rule filed September 7, 2001; effective November 21, 2001.