Request for Services

Personal Information

Expectant Mother
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Can we leave a message on this phone identifying ourselves?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your date of birth?
Due Date (or approximate). If child is already born, date of birth*
Gender of Baby (if known)
Are you receiving prenatal care?

YesNo
If yes, what is the name of your doctor or clinic? If you are not receiving care please say "not receiving care":
If yes, when did you start receiving care?
If no, do you need help finding a doctor or clinic?

YesNoUnsure
Have you had an ultrasound done?

YesNo
Do you have medical insurance?

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

YesNoNot Sure
If yes, how often do you feel this would be helpful?
Support System

Tell us about the important people in your life.
Please tell us who is aware of your pregnancy?*

Father of the babyMy motherMother of the baby's fatherMy fatherFather of the baby's fatherMy childrenFather's grandparentsMy grandparentsOther
Does anyone oppose your adoption plan?*

YesNoUnsure
If yes, who?
Do you have other children?*

YesNo
If yes, please list gender, date of birth and if you are currently parenting or placed any for adoption:
Marital Status*
Education
Religion
Eye Color
Hair Color
Height
Weight (Pre-Pregnancy)
Complexion
Your Hobbies and Interests
Race/Ethnicity
Describe your personality:
Describe Your General Mental Health
I am a registered member of a Native American Indian Tribe:*

YesNoUnsure
If yes, which one?
Are you currently employed?

YesNo
If so, what is your job?
Expectant Father

Please fill out what you know.
Name

First NameLast Name
Date of Birth/Age
Marital Status
Education
Religion
Eye Color
Hair Color
Height
Weight
Complexion
Hobbies and Interests
Race/Ethnicity
The expectant father is a member of a Native American Indian Tribe:

YesNoUnsure
If yes, which one?
Describe his personality:
Is he currently employed?

YesNoUnsure
What is his job?
Describe his General Mental Health:
Is he aware of your pregnancy?*

YesNoUnsure
If yes, does he agree with the adoption plan?

YesNoUnsure
If yes, will he sign relinquishment papers in favor of an adoption?

YesNoUnsure
Are his current whereabouts known?

YesNo
If yes, list any contact information you have for him:
What is the status of your relationship with him?*
Has he supported you financially during any part of this pregnancy?*

YesNo
Health Related Questions
Have you had any problems during this pregnancy?

YesNo
If so, please tell us about them:
Have you used any prescription medication during this pregnancy?

YesNo
If yes, please tell us 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?

YesNo
If so, please tell us which non-prescription medication was taken, the reason, and the approximate date(s) on which the medication was taken:
Have you used any marijuana products during this pregnancy?

YesNo
Have you used methamphetamines (meth) during this pregnancy?

YesNo
Have you used cocaine during this pregnancy?

YesNo
Have you used heroin during this pregnancy?

YesNo
Have you used any others drugs not mentioned above during this pregnancy?

YesNo
If you answered yes the any of these questions, please tell us what you used, when, and how much?
Have you used alcohol during this pregnancy?

YesNo
If yes, what kind of alcohol?
Please tell us what when, how often, and how much?
Have you smoked cigarettes during this pregnancy?

YesNo
If so, how often and how many?
Selection of Adoptive Family
Types of Adoptions (Choose Which Type):

Traditional AdoptionSemi-Traditional AdoptionSemi-Open AdoptionOpen AdoptionUnsure
Please tell us about the person/family you would like to adopt your baby:*
Do you require financial assistance from us?

YesNoNot Sure
I would like to receive the followng adoption related services:

Help with living expensesFinding a doctor for pre-natal careHelp getting medical insuranceAdoption counselingI would like to speak with someone who has placed a child for adoptionI would like adoption educationI have other questions (see box below)
Other Questions?
What would you like to see happen during your time working with us? What are your goals?*
How did you hear about us?*
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.

Browse Files

Cancelof
If you have an ID, please take a picture and upload it here:

Browse Files

Cancelof
If you have a copy of your insurance card, take a picture of it and upload it here.

Browse Files

Cancelof
Digital Signature*

First NameLast Name
Should be Empty:

Personal Information

Adoption Plan

Support System

Expectant Father

Health Related Questions

Selection of Adoptive Family

Document Uploads