Birthmother Application – Part 1

• Expectant/ Birthmother Applications - Part 1
• Expectant/ Birthmother Applications - Part 2
• Expectant/ Birthmother Applications - Part 3
• Expectant/ Birthmother Applications - Part 4

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  1Personal Information

  2Expectant Mother Information

  3Expectant Father Information

  4Medical History

  Has your baby already been born?

  NoYes

  Approximately when is your baby due?

  MM slash DD slash YYYY

  “We work with women who have children up to two (2) years of age.”

  What is your baby's date of birth?

  MM slash DD slash YYYY

  Full Name

  First Middle Last

  Please list any other names you have ever gone by (e.g. maiden name, married name).

  First Middle Last

  Full Address

  Street Address Apt. # City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code

  Date of Birth

  MM slash DD slash YYYY

  Age

  Your Place of Birth

  City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

  Social Security Number

  Cell Phone

  Ok to text?

  Yes

  No

  Ok to leave voicemail?

  Yes

  No

  Email Address

  Marital Status

  SingleMarriedSeparatedDivorcedIn a Relationship

  Have you ever been married?

  Select AnswerYesNo

  Do you have insurance?

  YesNo

  Do you have a valid ID?

  YesNo

  PLEASE UPLOAD A PHOTO OF ID AND/OR MEDICAL CARD

  Drop files here or Select files

  Max. file size: 512 MB.

  What is your race?

  What will the race of your baby be?

  Do you have Native American heritage?

  YesNo

  Do you have Tribal Enrollment?

  YesNo

  What is the name of your Tribe?

  Have you ever placed another child for adoption?

  YesNo

  Are you working?

  YesNo

  What type of work do you do?

  What type of work have you done in the past?

  Do you have other children?

  YesNo

  How many other children do you have?

  How old are your other children and with whom do they live?

  Do you know who the expectant/birth father is?

  YesUnknownCould be more than one man

  Race

  Are you in a relationship with the father of your baby?

  YesNo

  Does the father of your baby know that you are pregnant?

  YesNo

  Does the father of your baby know that you are planning an adoption for your baby?

  YesNo

  When was the last time you saw the father of your baby?

  When was the last time you communicated with the father of your baby?

  Where was the father of your baby living the last time you saw or spoke with him?

  City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State

  Please answer the following questions pertaining to YOUR drug/medical history:

  Prescription Drug Use

  Before Pregnancy

  During Pregnancy

  Never

  Alcohol Use

  Before Pregnancy

  During Pregnancy

  Never

  Marijuana Use

  Before Pregnancy

  During Pregnancy

  Never

  Street Drug Use

  Before Pregnancy

  During Pregnancy

  Never

  Drug Treatment Program

  Before Pregnancy

  During Pregnancy

  Never

  Are you Hepatitis C+?

  YesNoI don't know

  Are you HIV Positive?

  YesNoI don't know

  Please answer the following questions pertaining to mental health history:

  Anxiety

  Expectant Mother (you)

  Expectant Father

  Your other child(ren)

  Your extended family

  Expectant Father's Family

  None

  Depression

  Expectant Mother (you)

  Expectant Father

  Your other child(ren)

  Your extended family

  Expectant Father's Family

  None

  Bipolar Disorder

  Expectant Mother (you)

  Expectant Father

  Your other child(ren)

  Your extended family

  Expectant Father's Family

  None

  Schizophrenia/Schizoaffective Disorder

  Expectant Mother (you)

  Expectant Father

  Your other child(ren)

  Your extended family

  Expectant Father's Family

  None

  Autism/Asperger's

  Expectant Mother (you)

  Expectant Father

  Your other child(ren)

  Your extended family

  Expectant Father's Family

  None

  Other mental health diagnoses in expectant parents or their extended families, that are important to disclose:

  CAPTCHA