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Your First Name
Your Middle Name
Your Last Name
Cell Phone (with area code)
Other Phone (with area code)
Email Address
Social Security Number
Address
Address line 2
City
State
Zip
How did you hear about us?
When is Your Due Date?
Proof of Pregnancy?
yesno
Sex of Baby
femalemale
Have you received prenatal care during this pregnancy?
How is the health of the baby?
Any problems with pregnancy?
Expectant Mother Age
Birth Date
Ethnic Background:
WhiteBlackHispanicNative AmericanAsian
Do you have any Native American Blood?
If so, are you registered with a tribe?
Which Tribe?
Have you ever placed a child for adoption?
If yes, when?
Who helped you with the adoption? Please list any agency, attorney or facilitator.
Describe Your General Health:
Eye Color
Hair Color
Height
Weight
Have you ever been arrested? If so, explain.
Have you ever been diagnosed with mental illness, if so describe.
Have you consumed alcohol during this pregnancy, if so describe.
Have you done any prescription or other drugs during this pregnancy, if so describe.
Do you smoke?
What is the last grade you completed?
Have you ever been diagnosed with Hepatitis C?
Have you ever been diagnosed with HIV?
Are you currently employed?
Do you currently have medical coverage?
Are you open to meeting the family who adopts your baby?
Would you like pictures or updates after the baby is born?
Would you like visits after the baby is born?
Does your family know you are pregnant?
Does your family know about the adoption?
Does your family agree?
YesNo
Does anyone in your family oppose adoption?
If yes, who?
Do you have other children?
How Many?
Number of Boys
Number of Girls
Ages
Describe the general health of your children.
Do they live with you?
If they are not with you, where are they?
Do you know who the father of the baby is?
Is there a chance it could be anyone else?
If yes, explain
Expectant Father First Name
Expectant Father Last Name
Phone (with area code)
Date of Birth
Does he know about the adoption?
Does he support the adoption?
If he does not, will he oppose and try to parent?
Are you legally married to the expectant father?
Are you legally married to someone other than the expectant father?
What is your current relationship with the expectant father, describe.
Father's Ethnic Background:
Does he have any Native American Blood?
If so, is he registered with a tribe?
What is the last grade he completed?
Does anyone in his family oppose the adoption?
Describe fathers general health
Has the expectant father ever been diagnosed with mental illness, if so describe.
Why are you considering adoption?
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