• Personal Information 

    Expectant Mother
  • Format: (000) 000-0000.
  • Can we leave a message on this phone identifying ourselves?
  • Are you receiving prenatal care?*
  • D you need help finding a doctor or clinic?*
  • Have you had an ultrasound done?*
  • Do you have medical insurance?*

  • Adoption Plan

  • I feel that counseling would be helpful in making an adoption plan*

  • Support System

    Tell us about the important people in your life.
  • Please tell us who is aware of your pregnancy?*
  • Does anyone oppose your adoption plan?*
  • Do you have other children?*
  • I am a registered member of a Native American Indian Tribe:*
  • Are you currently employed?*

  • Expectant Father

    Please fill out what you know.
  • Do you know the identity of the father of the baby?*
  • Is he aware of your pregnancy?*
  • Has he supported you financially during any part of this pregnancy?*
  • Does he agree with the adoption plan?*
  • Will he support your adoption plan and sign relinquishment papers?*
  • The expectant father is a member of a Native American Indian Tribe:*
  • Is he currently employed?
  • Are his current whereabouts known?

  • Health Related Questions

  • Have you had any problems during this pregnancy?*
  • Have you used any prescription medication during this pregnancy?*
  • Have you taken any non-prescription medication during this pregnancy?*
  • Have you used methamphetamines (meth) during this pregnancy?*
  • Have you used any marijuana products during this pregnancy?*
  • Have you used cocaine during this pregnancy?*
  • Have you used heroin during this pregnancy?*
  • Have you used any others drugs not mentioned above during this pregnancy?*
  • Have you used alcohol during this pregnancy?*
  • Have you smoked cigarettes during this pregnancy?*

  • Selection of Adoptive Family

  • Types of Adoptions (Choose Which Type):
  • Do you require financial assistance from us?*
  • I would like to receive the followng adoption related services:*

  • Document Uploads

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