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(949) 463-3510
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FAQs for Expectant Mothers
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Call:
(800) 556-5635
| Text:
(949) 463-3510
|
Email
Expectant Mother Intake
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?
yes
no
Sex of Baby
female
male
Have you received prenatal care during this pregnancy?
yes
no
How is the health of the baby?
Any problems with pregnancy?
Expectant Mother Age
Birth Date
Ethnic Background:
White
Black
Hispanic
Native American
Asian
Do you have any Native American Blood?
yes
no
If so, are you registered with a tribe?
yes
no
Which Tribe?
Have you ever placed a child for adoption?
yes
no
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?
yes
no
What is the last grade you completed?
Have you ever been diagnosed with Hepatitis C?
yes
no
Have you ever been diagnosed with HIV?
yes
no
Are you currently employed?
yes
no
Do you currently have medical coverage?
yes
no
Are you open to meeting the family who adopts your baby?
yes
no
Would you like pictures or updates after the baby is born?
yes
no
Would you like visits after the baby is born?
yes
no
Does your family know you are pregnant?
yes
no
Does your family know about the adoption?
yes
no
Does your family agree?
Yes
No
Does anyone in your family oppose adoption?
yes
no
If yes, who?
Do you have other children?
yes
no
How Many?
Number of Boys
Number of Girls
Ages
Describe the general health of your children.
Do they live with you?
yes
no
If they are not with you, where are they?
Do you know who the father of the baby is?
yes
no
Is there a chance it could be anyone else?
yes
no
If yes, explain
Expectant Father First Name
Expectant Father Last Name
Address
City
State
Zip
Phone (with area code)
Email Address
Date of Birth
Does he know about the adoption?
yes
no
Does he support the adoption?
yes
no
If he does not, will he oppose and try to parent?
yes
no
Are you legally married to the expectant father?
yes
no
Are you legally married to someone other than the expectant father?
yes
no
What is your current relationship with the expectant father, describe.
Father's Ethnic Background:
White
Black
Hispanic
Native American
Asian
Does he have any Native American Blood?
yes
no
If so, is he registered with a tribe?
yes
no
Which Tribe?
Eye Color
Hair Color
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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