Birth Mother Questions

Name

First Last

Your Date of Birth

Preferred Name

First Last

Due Date of Your Baby:*

Baby's Gender*

Your Social Security Number:

(Not Required)

Do you have a state issued drivers license or ID card?

Yes
No

If Yes, please list the state in which it is issued:

Please list the license or ID card number:

(Not Required)

CONTACT INFORMATION

Address

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Home Phone

Cell Phone

May we contact you:

Home Number Yes
Home Number No
Cell Phone Yes
Cell Phone No
Email Yes
Email No

Emergency Contact*

*If there is someone who is aware that you are pregnant and considering adoption, please list their contact information above. We will only contact this person in case of an emergency.

First Name Last Name Relationship to You Phone Number

IDENTIFYING INFORMATION

Marital Status

Religion

Ethnicity (please check all that apply)

Hispanic
African American
Caucasian
Asian/South Asian
American Indian
Other

If American Indian, which tribe?

What is your national heritage (ex: Irish, Haitian, Puerto Rican, etc.

Height

Approximate Weight (before pregnancy)

Eye Color

Skin Color

Hair Color

Hair Texture

EDUCATION

Junior High (check current or highest grade completed)

6
7
8

High School (check current or highest grade completed)

9
10
11
12

College (check current or highest grade completed)

1
2
3
4

School Subjects of Interest

Please List any Learning Disabilities

Extracurricular School Activities and Hobbies:

Educational Plans:

EMPLOYMENT STATUS

Current Employment Status

Employed
Unemployed
Student

Employer Name

Length of time at current job

Previous Jobs Held:

INSURANCE INFORMATION

Do you have private health insurance or are you receiving assistance from Medicaid or any other government aid?

If YES, list name of carrier (ex: Blue Cross, Blue Shield, Humana

Policy Number

Health Insurance Address

Street Address Address Line 2 City State ZIP Code

Health Insurance Provider Phone Number:

Percentage of bills covered by insurance?

PRENATAL CARE

Have you received any prenatal care during this pregnancy?

Yes
No

If yes, in which month of pregnancy did you begin receiving prenatal care?

Your Doctor's Name

Please list the doctor/clinic where you have you received prenatal care:

Your Doctor's Address

Your Doctor's Office Phone Number

Your Doctor's Office FAX Number

The Percentage of bills covered by your Insurance

Have you had any previous pregnancies

If Yes, how many?

Have there been any problems or complications with this or previous pregnancies?

If Yes, please explain

Have you used drugs prior to or during this pregnancy?

If yes, please describe what substance was used and to what extent:

Do you smoke?

If yes, how much and how frequently:

Are you willing to have an HIV and/or drug test?

HOSPITAL INFORMATION

Please list the hospital where you plan to deliver:

Hospital Name

Hospital Address

Hospital Phone Number

Hospital Fax Number

CHILDREN INFORMATION

Was this Child Already Born?

Yes
No

If Yes, please indicate date of birth:

Race/Ethnicity of child (check all that apply)

African
American Indian
Asian/South Asian
Caucasian/White
Hispanic
Other

If American Indian, which tribe?

Have you ever placed a child for adoption before?

Yes
No

If Yes, please describe in detail

Do you have any other children?

Yes
No

If Yes, are they living with you?

Yes
No

If No, please describe the circumstances:

Do any of these children have the same biological father as your unborn baby?

THOUGHTS & FEELINGS ABOUT ADOPTION

Why are you considering/planning adoption for your child?

What are your hopes for your child’s future?

Who are the people who give you emotional support in life?

Does anyone in your family know about your pregnancy? Do they know you are considering adoption?

What would you like your child to know about you and your family?

What do you want out of life for yourself after the baby is born?

Is there anything else you would like us to know? We are here to help.

Comments or Questions

BIRTH MOTHER INFORMATION