Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
SSN#
*
Race
*
Are you registered with a native American tribe?
*
Yes
No
Are you legally married?
*
Yes
No
Have you ever placed a child for adoption before?
*
Yes
No
When did you place a child for adoption?
*
Describe your general health:
*
Please list any mental health illnesses in which you have been diagnosed:
*
Please list any prescription or other drugs consumed during this pregnancy:
*
How often and how much alcohol have you consumed during this pregnancy?
*
How often and how much do you smoke?
*
Do you have other children?
*
Yes
No
Number of girls:
*
Number of boys:
*
Do they live with you?
*
Describe the general health of your children:
*
Pregnancy Information
Due Date
*
-
Month
-
Day
Year
Date
Do you have proof of pregnancy?
*
Yes
No
Have you received prenatal care?
*
Yes
No
List any concerns/problems during the pregnancy:
*
Why are you considering adoption?
*
If you are working with an OBGYN at this time, please provide the doctor’s name and location:
*
Is your doctor aware of your possible adoption plan?
*
Yes
No
Hospital where you will deliver:
*
Do you have state issued Medicaid (a medical card):
*
Yes
No
Contact Level
Would you like to talk with the prospective adoptive parents prior to birth?
*
Yes
No
Would you like to meet the prospective adoptive parents prior to birth?
*
Yes
No
Would you like pictures and updates after the baby is born?
*
Yes
No
Would you like visits after the baby is born?
*
Yes
No
Extended Family
Does your family know you are pregnant?
*
Yes
No
Does your family know about the adoption?
*
Yes
No
How does your family feel about your decision?
*
Legal History
Have you ever been arrested?
*
Yes
No
Please explain:
*
Are you currently on probation?
*
Yes
No
Have you ever had your parental rights terminated either voluntarily or involuntarily?
*
Yes
No
Expectant Father Information
Is the father of the baby known?
*
Yes
No
Father's name
*
First Name
Last Name
Father's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father’s ethnic background:
*
Is he a member of a native American tribe?
*
Yes
No
Describe the father’s general health:
*
Has he been diagnosed with a mental illness?
*
Yes
No
Does he know about the pregnancy?
*
Yes
No
Does he know about the adoption?
*
Yes
No
Does he support the adoption?
*
Yes
No
Will he oppose and try to parent?
*
Yes
No
Does anyone in his family oppose the adoption?
*
Yes
No
Are you legally married to the expectant father?
*
Yes
No
What is your current relationship with the father?
*
Submit
Should be Empty: