Birthmother Application – Part 4

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

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  Financial Assistance Statement

  As is allowable by law, some states make it legal to provide a pregnant woman with financial assistance during the end of her pregnancy and during the time immediately following the birth of a child known as the post-partum period. This is usually a six-week period after the date of the birth of the baby. Generally, expenses that are legal in an adoption must be expenses that directly relate to the adoption. These expenses may include such things as medical care, hospital care, rent, utilities, maternity clothing, and groceries. In order to receive financial assistance, it is required that a financial need be proven that is not being met through help such as a medical care, food stamps, WIC, TANF, etc.

  It is required by adoption policy law that any financial help Adoptions with Love, Inc. provides must be documented. This documentation includes such things as copies of leases, or statements regarding room and board, receipts for maternity clothing and groceries, as well as copies of utilities bills. Adoptions With Love, Inc. is required to pay rent or room and board directly to the landlord as well as to pay any utilities, doctor, or hospital bills directly to the utility company, doctor, or hospital. Payment for allowable expenses is not contingent upon placing your baby for adoption.

  Consent(Required)

  I understand and agree that while I am receiving financial assistance from Adoptions With Love, I may not receive financial assistance from any other adoption entity. If I do receive any such assistance, I understand this constitutes fraud and I will be prosecuted to the fullest extent of the law.(Required)

  Consent(Required)

  I have read and understand the above financial assistance statement and agree to provide Adoption With Love, Inc. with all receipts and/or bills which may apply in my receiving financial help(Required)

  PREGNANT WOMAN’S FINANCIAL NEEDS FORM

  Adoptions With Love, Inc. is committed to helping you, as allowable by law, with pregnancy related financial needs. However, it is very important to know the law says that only pregnancy related expenses are allowable and that these expenses may be paid for a limited period of time. In general, that period of time is the latter part of the pregnancy and up to 6-8 weeks after the birth of the baby.

  By telling us what your average monthly expenses are, we can help you in making a plan that will meet your needs and, at the same time, meet the requirements of the law.

  Monthly Expenses

  Rent or room and board:

  Utilities

  Gas

  Gas

  Electricity

  Electricity

  Phone Bill

  Which phone carrier do you have?

  AT&T, T-Mobile, Cricket, etc

  Food:

  if not provided by WIC or food stamps

  Transportation:

  Gas or Uber fare, if needed, to and from doctor’s appointments

  Counseling:

  Adoption counseling is provided if you wish, before the birth of the baby. After your baby joins his/her adoptive family, the cost of counseling, up to $1,000.00, is additionally covered.

  Maternity Clothing:

  A one-time allowance up to $150.00

  Do you have private insurance, such as Blue Cross & Blue Shield, HMO, etc.?

  Yes

  No

  If yes, what is your private insurance number?

  Do you have Medicaid or a medical card, such as Access, Healthy Start, etc. ?

  Yes

  No

  If you have Medicaid, what is your Medicaid Number?

  Please note: Assuming you choose to complete your adoption plan through Adoptions With Love, Inc., you may receive financial assistance with doctor and hospital bills relating to usual and customary charges for pre-natal care, the birth of the baby and hospital care immediately following the birth for you and your baby. This program applies if you have no insurance or if you do not qualify for Medicaid or a medical card after filling out all Medicaid required forms and providing all Medicaid required documents.

  Consent(Required)

  I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)

  ADOPTIONS WITH LOVE, INC.

  PHOTO AGREEMENT FOR BIRTHPARENTS

  As a birth mother you have the option to receive pictures of the child you placed for adoption. Each adoptive family who adopts a child through Adoptions With Love, Inc. signs a legally binding agreement with Adoptions With Love, Inc. agreeing to send the Agency photos of the adopted child at ages 1 month, 3 months, 6 months, 12 months, and within 30 days of the child's 2nd birthday, 3rd birthday, 4th birthday and 5th birthday. Once your child reaches the age of 6 (and through his/her 18th birthday), at your request, Adoptions With Love, Inc. will get in touch with your child’s adoptive parent(s) and request that they send in a letter and photographs, within 30 days after your child’s birthday, to our office. These materials will then be forwarded along to you. If you wish to request these annual updates, you may call our office (toll-free) at 800-722-7731 or contact us via email at info@awlonline.org. PLEASE NOTE THAT YOU MUST CONTACT ADOPTIONS WITH LOVE EACH YEAR THAT YOU WANT YOUR PICTURES. THEY ARE NOT REQUESTED FROM THE FAMILY OR SENT TO YOU AUTOMATICALLY.

  You are not required to receive these materials. If you do not want them, you do not need to do anything. AWL will hold these materials at the office for you in the event that you wish to receive them down the road. If there is a time in the future that you do want these materials, you can contact the agency and we will send the materials along to you by mail.

  Additionally, you may choose to join online photo sharing sites set up by the adoptive parents. These may be created through Shutterfly, Google Photos, iCloud photo albums, etc. The adoptive parents may add photos at various points in the child's life, allowing birth parents to view them whenever they please. In some cases, birth parents may be able to share photos as well for the adoptive family to see. Shared online photo sites will be used on a case-by-case basis depending on the birth parent's wishes and an agreement with the adoptive family. If you want ongoing, in-person visits with the child, Adoptions With Love will facilitate a legally binding written agreement between you and the child's adoptive parents to outline these visits. You are not required to schedule in-person visits. These agreements will be used on a case-by-case basis depending on the birth parent's wishes.

  Your signature on this page means that you have read the above photo policy, and that you understand and accept the terms of the policy. PLEASE NOTE THAT ADOPTIONS WITH LOVE, INC. IS LEGALLY ABLE TO ENFORE THE SPECIFIC TERMS OF THIS AGREEMENT. HOWEVER, WE ARE UNABLE TO ENFORCE THE TERMS OF ANY VERBAL OR OTHER SUBSEQUENT AGREEMENT THAT MAY HAVE OCCURED BETWEEN YOU AND THE ADOPTIVE PARENTS OF YOUR CHILD. It also means that you have received notification of this policy in writing.

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)

  YOUR PERSONAL PREFERENCES

  1. I give permission to Adoptions With Love to provide identifying information to my child when he/she reaches age of consent (age 21) should he/she request it or desire to find me.

  Yes

  No

  2. I understand that Adoptions With Love, Inc. urges me to take advantage of counseling before the baby is born and after the placement of the child. I understand that Adoptions With Love, Inc. will pay for the expense of counseling while I am pregnant and will pay up to $1,000.00 for post-placement counseling.

  Yes

  No

  3. I understand that I may request that pictures and/or updates of my child be sent to me at ages 1 month, 3 months, 6 months, 1 year and then yearly, within 30 days of the child's birthday. NOTE: this information is not sent automatically, you must request this information in writing or by phone from the agency.

  Yes

  No

  4. I would like to share photos, gifts, letters or pictures of myself or my immediate family with the adoptive family. I understand that these would be sent to Adoptions With Love, Inc. who would pass them on to the adoptive family.

  Yes

  No

  5. I would like to receive information about the adoptive family, their interests, their background, and ability to raise children.

  Yes

  No

  6. I understand and authorize Adoptions With Love, Inc. and any agent of Adoptions With Love, Inc. to tape our conversations, tape when I sign a formal Relinquishment of Parental Rights, and any other necessary legal or agency documents required for the placement of my child for adoption.

  Yes

  No

  7. In the extremely unlikely event that the child's adoptive parents should die without leaving a will prior to the legal finalization of the adoption by court order, I wish to be contacted by Adoptions With Love, Inc. to take part in the planning of the child.

  Yes

  No

  8. After the finalization of the adoption by court order, should the child die or develop a medical condition which is determined by Adoptions With Love, Inc. to be serious and may impact any future children, would you wish to be notified?

  Yes

  No

  9. All families approved through Adoptions With Love, Inc. are evaluated to have excellent family and moral values. However, if you do a have a religious preference for your baby it will be honored. Do you have a religious preference for your child?

  Yes

  No

  If yes, what is your religious preference?

  10. I understand I have a right to have my own lawyer. I understand that the lawyer that represents Adoptions With Love, Inc. does not represent me.

  Yes

  No

  11. I wish to have a lawyer of my own choosing.

  Yes

  No

  12. I allow Adoptions With Love, Inc. to release identifying information to the prospective adoptive parent(s) of my child at this time. Identifying information may include my full name, my address, my social security number, etc.

  Yes

  No

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)

  INFORMATION FOR PARENTS CONSIDERING SURRENDERING A CHILD FOR ADOPTION

  Sometimes parents are faced with situations that require them to consider making an adoption plan for their child. Adoptions With Love, Inc. is prepared to help you reach a decision that will be in the best interest of your child and family. The following information is provided to you to explain your rights before, during and after the process: the types of adoptions and the process used to select an adoptive family.

  FACTS ABOUT SURRENDER AND ADOPTION

  A surrender is a legal document in which you agree and consent to the adoption of your child. If you decide that adoption surrender is the best plan for you and your child, you should be aware of the following procedures, rights and restrictions.

  1. Each state has its own laws relating to when you can sign papers allowing adoption.

  2. You cannot sign anything allowing a child to be adopted before he or she is born.

  3. In some states, it is legal to sign papers allowing an adoption immediately after birth. Some states require that a certain number of hours or days must go by before anything can be signed allowing adoption.

  4. In some states, after you sign papers allowing an adoption, there is a period of time known as a revocation period, during which you have the right to change your mind and your child will be returned to you. In those cases, once the revocation period has expired, your child can never be returned to you.

  5. In some states it is required that papers be signed before a judge; however, in other states, this is not required.

  6. In every state, once you sign an adoption surrender and/or consent and the revocation period goes by, if you change your mind, you will no longer have any rights to the child. It is extremely important that you talk with an attorney and/or the social worker about the legal procedure in your state and your legal rights. You have the right to an attorney of your own choosing that will represent your interests in an adoption. The attorney who represents Adoptions With Love, Inc. does not represent you.

  TYPES OF ADOPTION

  The type of adoption plan that is developed for your child is based on what is in your child’s best interest. The staff at Adoptions With Love will help to design an adoption with which you are comfortable. The relationship that you develop with your child’s adoptive family will be unique and change over time. Adoptions With Love is committed to help negotiate this relationship and the amount of contact you have with the adoptive family. In some cases, such as in the adoptive placement of an older child or when the child and the adoptive parents are related, an open adoption placement is made. By open adoption placement we mean the identities of the adoptive parent(s) and the birth parents are exchanged and the post-placement direct contact may occur between the birth parents and the adoptive parents that legally cannot be enforced by Adoptions With Love. Even though there may be some degree of openness, because of this agreement the adoptive parents still hold full parental rights and responsibilities for the child. Adoptions With Love places most children with families who reside in Massachusetts unless you specifically request your child to be placed in a state other than Massachusetts.

  Adoptions With Love will act as an intermediary between you and the adoptive family and your child if you wish to send your child any written information, provide your child with photos, or with other gifts or mementos. All adoptive families have clearances completed to make sure there is no known history of criminal activity, drugs, alcohol or abuse/neglect.

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)

  FACTS ABOUT SELECTING ADOPTIVE PARENTS

  -You may request that your child be placed with an adoptive family of your same religious, racial and/or ethnic background. All efforts will be made to honor your request by Adoptions With Love.

  - All adoptive families must complete a special training program that develops their understanding of how to best meet children’s needs. This includes information about child development, explaining adoption to children, baby care, etc.

  - Adoptions With Love runs criminal background checks on the applicants and members of their households to determine if they have criminal records that would make them unsuitable to raise children. Adoptions With Love also runs child abuse and neglect checks on the applicants and members of their households.

  - Adoptions With Love receives references regarding all applicants to determine if their friends, neighbors, and co-workers consider them to be suitable to be adoptive parents.

  - A Social Worker from Adoptions With Love meets with the applicants to determine if they can provide a safe home and a good family life for a child.

  - Applicants must obtain a statement from a physician confirming that they have no health problems that would interfere with raising a child.

  - You may request that your child be placed with a particular family for adoption. This is called a designated adoption. However, the decision for placement will be the responsibility of Adoptions With Love. In the unlikely event that the family you select for your child is unable, for unforeseen reasons, to receive placement of the child, Adoptions With Love will use its sole discretion in selecting a family that is as close to the family you had selected as possible. Adoptions With Love will inform you if the family you selected for your child is unable to adopt your child. If this should happen, Adoptions With Love will make every attempt to have you participate in the selection of another family for your child.

  - If a specific family has been selected for your child, you will be provided with certain information. This will be non-identifying and will state why it is believed this family will meet your child’s needs. If you do not wish to receive this information, you will be asked to sign a document stating that.

  AFTER THE ADOPTION

  NOTIFICATION REGARDING DISRUPTION

  You may request that you be notified in case the adoption doesn’t work out to take part in the planning for your child.

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)

  INFORMATION THAT CAN BE OBTAINED

  All records of children adopted through Adoptions With Love are confidential. The law allows certain information to be released to certain people. The request must be submitted in writing. Adoptions With Love will release the following information:

  - An adopted person who has reached the age of 21 can receive identifying information about his/her biological parents with the biological parent’s written permission and/or according to the laws of the state where the child was born. This identifying information could lead to the biological parent’s present or former location.

  - A Birthparent of an adopted person can receive information about the adopted person that will not identify the child or his/her present or former location.

  - The law also permits Adoptions With Love, at its discretion, to release other non-identifying information of the circumstances surrounding an adoption.

  Information not listed above can be released either with a written order from the Probate Court which conducted the adoption proceedings, or with written consent to the parties involved.

  You may request general information regarding current adoption issues, practices, and laws from your social worker.

  PROCEDURE FOR PUTTING INFORMATION INTO YOUR RECORD

  You are encouraged to include family pictures and a letter in your family case record. At any time in the future, you have the right to contact Adoptions With Love to add any new information about yourself to the case record. Such information may include but is not limited to a new name, new address, birth of new siblings, new health or psychiatric information regarding yourself or other biological relatives of the child, and your wishes regarding release of such information to your child or his/her adoptive parents.

  RECEIVING INFORMATION ABOUT YOUR BABY AFTER PLACEMENT

  All families who adopt through Adoptions With Love provide the Agency with at least 10 photos of the child and a letter describing the child’s development for five years after the date of placement with the adoptive family. Each family sends photos of the infant at age one month, three months, six months and twelve months, two years, three years, four years, and five years. They also send a letter describing the child’s adjustment at these intervals. This information will be given at your request. You may also request letter updates after 5 years for the family to continue to send yearly updates until the child reaches the age of 18.

  RELEASING IDENTIFYING INFORMATION ABOUT YOU TO YOUR CHILD

  Massachusetts law allows for identifying information about you (i.e., your name and last known address) to be released to your child when your child reaches the age of 21 and if your child requests the information. PLEASE NOTE that all children born after January 2008 can have access to their birth certificates once they reach the age of 18. During your counseling with Adoptions With Love we will ask you to sign a form stating whether you do or do not want your name and address released to your child if he or she requests this information. If the child you place for adoption through Adoptions With Love requests information about you prior to their 21st birthday, Adoptions With Love will contact you and ask your permission to do so. If it is important for you to have your child know your name and last known address, we encourage you to keep the Agency informed as the years go by regarding your address and how your child might contact you, if it is his or her desire in the future.

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)

  ALTERNATIVES TO ADOPTION

  There are many choices available to you concerning what to do about your unplanned pregnancy. Adoption is one of those choices. There are also other alternatives. The following is a list of some services available to you if you have the need. Further information can be obtained about any of these services through calling your local Department of Social Services. The telephone number is usually available by calling Information (411). Your case worker at Adoptions with Love, Inc. can also discuss these services with you, and at your request can help refer you to appropriate sources who can meet your needs.

  TANF (Welfare): Temporary Assistance for Needy Families provides financial assistance to families so that children may be cared for in their own homes. Contact your local TANF Office for more information.

  MEDICAID: Medicaid is health insurance that helps many people who cannot afford medical care pay some or all of their medical bills. For more information call The Centers for Medicine and Medicaid Services toll-free at 1-800-633-4227.

  FOOD STAMPS: Food stamps enable low-income households to buy the food they need for a nutritionally adequate diet. Nutritious food can be purchased with coupons or Electronic Benefits Transfer (EBT) cards. Contact your local Food Stamp Office for more information.

  SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC): WIC serves to safeguard the health of low-income women, infants, and children up to age 5 who are at nutritional risk by providing nutritious foods to supplement their diets. Applications are available through health care centers and your Department of Public Welfare.

  PUBLIC HOUSING: Public Housing provides apartments for low-income persons operated by local housing agencies. Contact your local housing authority for more information.

  CHILD CARE: If you go to school or work, you may qualify for financial assistance with your childcare expenses. To find out more call Child Care Aware of America toll-free at 1-800-424-2246.

  FOSTER CARE: If you are unable to care for your child at home at this time, you may place your child in foster care. Foster care means your child would be taken care of for a temporary period of time with the goal of helping you make a plan for your child to return home to you.

  EMERGENCY SHELTER: If you are in a crisis situation or in transition and do not have a place to live, you may be able to find a place to live in a short-term shelter. For domestic violence help, call the National Domestic Violence Hotline toll-free at 1-800-799-7233.

  COUNSELING SERVICES: Your counselor can help refer you to a range of therapeutic programs. Services are offered by professional counselors or through self-help programs such as Alcoholics Anonymous or Parents Anonymous (for parents who are experiencing parental stress, etc.).

  PARENTAL SUPPORT: Whenever possible, Adoptions With Love, Inc. strongly encourages each pregnant woman to share the fact of her pregnancy and the impending birth of her child with appropriate family members. It may be possible that the family could provide both emotional and financial help.

  SINGLE PARENTHOOD: For some women facing an unplanned pregnancy, single parenthood may be an option. Today there are many women who raise children as single parents. The other resources discussed in this hand-out may be available to you.

  Consent(Required)

  I HAVE READ AND UNDERSTAND THE ALTERNATIVES TO ADOPTION. I AM AWARE THERE ARE OPTIONS FOR ME OTHER THAN ADOPTION.(Required)

  GRIEVANCE AND APPEALS PROCEDURE

  If an adoptive parent(s), a birth parent, or a foster parent has a grievance with the Agency, they shall write a letter to the Agency Director, explaining, in detail, their view of the situation. Within ten working days after receipt of the letter, a meeting will be scheduled to discuss the grievance. If the parent(s), birth parents, or foster parents’ social worker is also the Agency Director, the grievance will be immediately relayed to an independent social work consultant. The result of this meeting will be sent, in writing, within one week of the meeting, to the complainant.

  If the adoptive parent(s), foster parent, or birth parent still feel their concern has not been sufficiently resolved, they may appeal to the Board of Directors in writing. Within fifteen business days from the receipt of the request for an appeal, a meeting will be held with the Agency Board of Directors to further discuss the grievance. The decision of the Board of Directors is final and will be sent, in writing, within one week from the meeting to the complainant.

  Adoption With Love, is a not- for- profit tax exempt agency holding the IRS tax exempt # of 042921324. The agency is licensed by the Department of Early Education and Care located at 360 Merrimack St., Building #9 Lawrence, MA 01843, and the telephone number is 978-681-9684. Should you have any concerns which you wish to discuss with the Department of Early Education and Care, feel free to contact that agency.

  Consent(Required)

  I have read and understood the Grievance and Appeals Procedure of Adoptions With Love, Inc.(Required)

  Native American Heritage

  Please check one of the statements below and then sign and date this form.

  I confirm that I do not have Native American Heritage.

  I confirm that although I may have Native American Heritage, I do not have any tribal affiliation.

  I confirm that I do have Native American Heritage with:

  Tribe

  (tribe)

  in

  State

  (State)

  Name(Required)

  First Last

  Signature

  Consent(Required)

  I have read the information as written, and it is true to the best of my knowledge.(Required)