Personal Information
Expectant Mother
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Can we leave a message on this phone identifying ourselves?
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your date of birth?
*
Due Date (or approximate). If child is already born, date of birth
*
Gender of Baby
*
Please Select
Girl
Boy
Unknown
Are you receiving prenatal care?
*
Yes
No
What is the name of your doctor or clinic? If you are not receiving care please say "not receiving care":
*
When did you start receiving care?
D you need help finding a doctor or clinic?
*
Yes
No
Unsure
Have you had an ultrasound done?
*
Yes
No
Do you have medical insurance?
*
Yes
No
Not sure
What is the name of your medical insurance?
Adoption Plan
Please tell us why you are considering an adoption plan
*
Which of the following best describes your feelings at this point regarding adoption:
*
Please Select
I know that making an adoption plan is the best decision. I feel 100% sure.
I am almost sure that adoption is best. I want to consider all my options.
I am confused about what to do.
I am only considering adoption because other people want me to.
I would really like to parent but I want adoption information just in case.
I am only interested in receiving information on parenting.
I feel that counseling would be helpful in making an adoption plan
*
Yes
No
Not Sure
How often do you feel counseling would be helpful?
Please Select
Weekly
Monthly
As needed
Support System
Tell us about the important people in your life.
Please tell us who is aware of your pregnancy?
*
Father of the baby
My mother
Mother of the baby's father
My father
Father of the baby's father
My children
Father's grandparents
My grandparents
Other
Does anyone oppose your adoption plan?
*
Yes
No
Unsure
Who?
Do you have other children?
*
Yes
No
Please list gender, date of birth and if you are currently parenting or placed any for adoption:
Marital Status
*
Please Select
Single
Married
Widowed
Divorced
Education
*
Please Select
Some High School
High School
Some College
Associates
Bachelors
Technical School
Other
Religion
Eye Color
*
Please Select
Blue
Brown
Green
Hazel
Natural Hair Color
*
Please Select
Blonde
Brown
Black
Red
Other
Height
*
Weight (Pre-Pregnancy)
*
Complexion
*
Your Hobbies and Interests
*
Race/Ethnicity
*
Describe your personality:
*
Describe Your General Mental Health
*
Please Select
Excellent
Good
Average
Poor
Other
I am a registered member of a Native American Indian Tribe:
*
Yes
No
Unsure
Which one?
Are you currently employed?
*
Yes
No
What is your job?
Expectant Father
Please fill out what you know.
Do you know the identity of the father of the baby?
*
Yes
No
Prefer not to say
Is he aware of your pregnancy?
*
Yes
No
Unsure
What is the status of your relationship with him?
*
Has he supported you financially during any part of this pregnancy?
*
Yes
No
Does he agree with the adoption plan?
*
Yes
No
Unsure
Will he support your adoption plan and sign relinquishment papers?
*
Yes
No
Unsure
Name
First Name
Last Name
Date of Birth/Age
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Unknown
Education
Please Select
Some High School
High School Diploma
Some College
Associates Degree
Bachelors Degree
Unknown
Religion
Eye Color
Please Select
Blue
Brown
Green
Hazel
Unknown
Hair Color
Please Select
Blonde
Brown
Black
Red
Other
Unknown
Height
Weight
Complexion
Hobbies and Interests
Race/Ethnicity
The expectant father is a member of a Native American Indian Tribe:
*
Yes
No
Unknown
Which one?
Describe his personality:
Is he currently employed?
Yes
No
Unsure
What is his job?
Describe his General Mental Health:
Please Select
Excellent
Good
Average
Poor
Other
Are his current whereabouts known?
Yes
No
Please list any contact information you have for him:
Health Related Questions
Have you had any problems during this pregnancy?
*
Yes
No
Please tell us about them:
Have you used any prescription medication during this pregnancy?
*
Yes
No
Which prescription medication was taken, for it is prescribed for, and the approximate date(s) on which the prescription was taken:
Have you taken any non-prescription medication during this pregnancy?
*
Yes
No
Which non-prescription medication was taken, the reason, and the approximate date(s) on which the medication was taken:
Have you used methamphetamines (meth) during this pregnancy?
*
Yes
No
Have you used any marijuana products during this pregnancy?
*
Yes
No
Have you used cocaine during this pregnancy?
*
Yes
No
Have you used heroin during this pregnancy?
*
Yes
No
Have you used any others drugs not mentioned above during this pregnancy?
*
Yes
No
Please tell us what you used, when, and how much?
Have you used alcohol during this pregnancy?
*
Yes
No
What kind of alcohol?
Please Select
Wine
Beer
Hard Liquor
Please tell us what when, how often, and how much?
Have you smoked cigarettes during this pregnancy?
*
Yes
No
On average how many and how often?
Selection of Adoptive Family
Types of Adoptions (Choose Which Type):
Traditional Adoption (closed)
Semi-Traditional Adoption
Semi-Open Adoption
Open Adoption
Unsure
Please tell us about the person/family you would like to adopt your baby:
*
Do you require financial assistance from us?
*
Yes
No
Not Sure
I would like to receive the followng adoption related services:
*
Help with living expenses
Finding a doctor for pre-natal care
Help getting medical insurance
Adoption counseling
I would like to speak with someone who has placed a child for adoption
I would like adoption education
I have other questions (see box below)
What would you like to see happen during your time working with us? What are your goals?
*
Questions?
How did you hear about us?
*
Please Select
Internet Search
Website
Facebook
Friend
Pregnancy Event
Other
Document Uploads
If you need immediate assistance, please upload your documents here.
If you have a proof of pregnancy, take a picture of it and upload it here.
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If you have an ID, please take a picture and upload it here:
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If you have a copy of your insurance card, take a picture of it and upload it here.
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Digital Signature
*
First Name
Last Name
Submit
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