Form Dss-5030 - Confidential Intermediary Agreement - Nc Family Support And Child Welfare

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CONFIDENTIAL INTERMEDIARY AGREEMENT
The undersigned parties voluntarily enter into this Confidential Intermediary Agreement and
hereby agree as follows:
1. The applicant, ___________________, and the ______________ County Department of
Social Services (“agency”) agree that the agency shall provide confidential intermediary
services, pursuant to N.C.G.S. 48-9-104(b), in an effort to obtain current non-identifying
health and background information from the applicant’s  biological parents
 biological grandparents or  adult adopted child and determine their willingness to
share identifying information with the applicant and/or have contact with the applicant.
OR
The applicant(s), _________________________________, and the ______________
County Department of Social Services (“agency”) agree that the agency shall provide
confidential intermediary services, pursuant to N.C.G.S. 48-9-104(b), in an effort to
obtain current non-identifying health information from the birth family of the minor
adoptee.
2. The applicant acknowledges that the applicant has executed a Release of Liability and
Agreement to Hold Harmless with regard to these services.
3. The applicant further acknowledges that the agency cannot guarantee that it will be able
to obtain the information or locate the person(s) sought. Nor can the agency guarantee the
receptivity or willingness of any located person for contact or the sharing of identified
information with the applicant.
4. For a nonrefundable fee of $____, the agency agrees to conduct an in-house record
review and a diligent search for the person listed above, including, but not limited to, an
internet based search, and to initiate contact with any person found in an attempt to obtain
current non-identifying health and background information and to ascertain that person’s
willingness to share identifying information or have contact with the applicant. In the
event confidential intermediary services are provided to the adoptive parent(s) of a minor
adoptee, the agency’s role shall be limited to a search for the adoptee’s birth parents and
the attempt to obtain current non-identifying health information.
5. Any initial search pursuant to this agreement will be conducted for a period of 90 days,
after which a written report will be sent to the applicant with the results of the search.
6. If this initial search is not successful, the agency agrees to continue providing
confidential intermediary search services with the written consent of the applicant at a
cost of $____ per hour  for a period of another 90 days or  to provide such additional
services up to a limit of $________.
DSS-5030 (09/08)
Family Support and Child Welfare

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