Start the Adoption Process version 2

Considering starting the adoption process?

This does not obligate you in any way shape or form. All this form does is get the process started just in case you decide to move forward.

Birth Mother Questions

- Step 1 of 15

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What is your preferred method of contact *

Can we leave you a message identifying ourselves as an adoption agency? *

HOw did you hear about us? *

Facebook
Instagram
Google
Other

The Basics

Who do you live with? *

How long have you lived there? *

Your date of birth? *

Where were you born? *

City, State

Marital Status *

Single
Married
Divorced
Widowed
Separated

Have you been married in the last 12 months? *

What is your maiden name or any other name you go by other than your legal name? *

Do you have health insurance? *

Do you have medicaid? *

Physical Information

How tall are you? *

feet + inches

What was your pre-pregnancy weight *

What is your natural hair color? *

What is your eye color *

Blue
Brown
Green
Hazel
Amber
Gray

What is your religion? *

Are you or anyone in your family part or entirely Native American Indian? *

Are they registered with a tribe? *

Education

Are you in school now? *

What are you studying? *

Do you have your high school diploma? *

Do you have your GED? *

What grade did you complete in school? *

Were you in special education classes? *

Were you in Advanced Placement classes? *

Have you taken any college classes? *

Employment

Are you working now? *

Where do you work? *

What are your normal work hours? *

Does your employer know you're pregnant? *

If you are not working, how do pay your bills? *

Your Children

How many other children do you have? *

I don't have any other children
1
2
3
4
More than 4

Child #1

What is your first child's name? *

What is your first child's age? *

What is your first child's gender? *

What are your first child's medical or special needs? *

Where does your first child currently live? *

Child #2

What is your second child's name? *

What is your second child's age? *

What is your second child's gender? *

What are your second child's medical or special needs? *

Where does your second child currently live? *

Child #3

What is your third child's name? *

What is your third child's age? *

What is your third child's gender? *

What are your third child's medical or special needs? *

Where does your third child currently live? *

Child #4

What is your fourth child's name? *

What is your fourth child's age? *

What is your fourth child's gender? *

What are your fourth child's medical or special needs? *

Where does your fourth child currently live? *

Your Family

Do you know about your parent's relationship? Please check all that apply. *

Never married
Married
Good relationship
Divorced
Still together
Hostile relationship

How many brothers do you have? *

How many sisters do you have? *

How many step brothers do you have? *

How many step sisters do you have? *

How many half brothers do you have? *

How many half sisters do you have? *

Is your family aware of your pregnancy? *

Is your family aware of your adoption plan? *

Does your family support your adoption plan? *

Have you considered anyone in your family to raise or parent your baby/child? *

Who have you considered? *

Medical History

Have you ever had a serious illness or accident? *

Please tell us about any serious medical illness, disease, or accident. *

List any allergies you have: *

Please list any health problems you have now: *

Have you ever been diagnosed with a mental health problem? (ex: depression, anxiety, bipolar disorder, etc...) *

Please tell us more about your mental health diagnosis. *

Have you ever been prescribed any medication for a mental health diagnosis? *

What medications have you been prescribed for mental health? *

Substances

Please check any substances you have used in the past year.

Alcohol
Cigarettes
Vaping
Marijuana
Caffeine
Sleeping pills
Anti-depressants
Diet pills
Steroids
Accutane
Lithium
Methamphetamines
Tranquilizers
Blood pressure pills
Antibiotics
Barbituates
Cortizone
Hormones
Stimulants
Ecstasy
Cocaine/Crack
Heroin
Methadone/Suboxone
Amphetamines
Inhalents

Please check any substances you have used in the last month.

Alcohol
Cigarettes
Vaping
Marijuana
Caffeine
Sleeping pills
Anti-depressants
Diet pills
Steroids
Accutane
Lithium
Methamphetamines
Tranquilizers
Blood pressure pills
Antibiotics
Barbituates
Cortizone
Hormones
Stimulants
Ecstasy
Cocaine/Crack
Heroin
Methadone/Suboxone
Amphetamines
Inhalents

Please check any substances you have used in the last week.

Alcohol
Cigarettes
Vaping
Marijuana
Caffeine
Sleeping pills
Anti-depressants
Diet pills
Steroids
Accutane
Lithium
Methamphetamines
Tranquilizers
Blood pressure pills
Antibiotics
Barbituates
Cortizone
Hormones
Stimulants
Ecstasy
Cocaine/Crack
Heroin
Methadone/Suboxone
Amphetamines
Inhalents

Please check any substances you are using daily.

Alcohol
Cigarettes
Vaping
Marijuana
Caffeine
Sleeping pills
Anti-depressants
Diet pills
Steroids
Accutane
Lithium
Methamphetamines
Tranquilizers
Blood pressure pills
Antibiotics
Barbituates
Cortizone
Hormones
Stimulants
Ecstasy
Cocaine/Crack
Heroin
Methadone/Suboxone
Amphetamines
Inhalents

Your Pregnancy

Your due date *

How many weeks along are you? *

Baby's gender *

Male
Female
Unknown

Baby's race

Caucasion
African American
Hispanic
Asian
Native American Indian
Pacific Islander
Other

Have you started prenatal care? *

Do you need help arranging prenatal care? *

If you have had any accidents, falls, or injuries during your pregnancy, please describe them. If none, just type "none". *

Please describe any physical abuse you have encountered during your pregnancy. If none, type "none". *

Please describe any problems, illnesses, or complications you may have had during this pregnancy. If none, type "none". *

Please list any medications you are currently taking. If none, type "none". *

Do you smoke cigarettes? *

How much do you smoke? Please tell us how many cigarettes or packs per day on average. *

Please describe any alcohol use during your pregancy. *

Birth Father Involvement

Potential birth father's name(s) *

List anyone who could be a birth father. If the name is not known you can say "unknown" or if you are not naming him, say "not naming".

Do you know where he is? *

Is he the father of any of your other children? *

Are you married to him? *

Is he aware of your pregnancy? *

Is he aware of your adoption plan? *

Does he agree with your adoption plan? *

Has he supported you emotionally? *

Has he supported you financially during this pregnancy? *

Is he currently supporting you financially? *

Please describe his involvement during your pregnancy. *

Is there anything else we should know about his intentions? *

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