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Birthmother Application – Part 1
Expectant/ Birthmother Applications - Part 1
Expectant/ Birthmother Applications - Part 2
Expectant/ Birthmother Applications - Part 3
Expectant/ Birthmother Applications - Part 4
1
Personal Information
2
Expectant Mother Information
3
Expectant Father Information
4
Medical History
Has your baby already been born?
No
Yes
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Date of Birth
MM slash DD slash YYYY
Age
Your Place of Birth
City
State / Province / Region
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Social Security Number
Cell Phone
Ok to text?
Yes
No
Ok to leave voicemail?
Yes
No
Email Address
Marital Status
Single
Married
Separated
Divorced
In a Relationship
Have you ever been married?
Select Answer
Yes
No
Do you have insurance?
Yes
No
Do you have a valid ID?
Yes
No
PLEASE UPLOAD A PHOTO OF ID AND/OR MEDICAL CARD
Drop files here or
Select files
Max. file size: 16 MB.
What is your race?
What will the race of your baby be?
Do you have Native American heritage?
Yes
No
Do you have Tribal Enrollment?
Yes
No
What is the name of your Tribe?
Have you ever placed another child for adoption?
Yes
No
Are you working?
Yes
No
What type of work do you do?
What type of work have you done in the past?
Do you have other children?
Yes
No
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?
Yes
Unknown
Could be more than one man
Race
Are you in a relationship with the father of your baby?
Yes
No
Does the father of your baby know that you are pregnant?
Yes
No
Does the father of your baby know that you are planning an adoption for your baby?
Yes
No
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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+?
Yes
No
I don't know
Are you HIV Positive?
Yes
No
I 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
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Expectant/Birthparents
Meet Our Families
Free Services
Make An Adoption Plan
Open Adoptions
Closed Adoptions
Is Adoption The Right Choice?
Birthmother Stories
Expectant/Birthparent FAQ
Adoptive Parents
The Adoption Process
Adoptive Parents Stories
Adoptive Parents FAQ
Resources
Florida Only Birthmother Application
Birthmother Application
Prenatal Records
Hospital Records
Pediatrician Release
Birthfather Application
Search & Reunion
Adopted Children’s Stories
Infographics
E-Books
About Us
Staff & Board
News & Events
Newsletters
Contact