Born Baby Application – Part 1

• My Baby Has Been Born Application - Part 1
• My Baby Has Been Born Application - Part 2
• My Baby Has Been Born Application - Part 3
• My Baby Has Been Born Application - Part 4

• Considering Adoption After Your Baby Is Born

  We understand that considering adoption for your child is a deeply personal decision. Please share as much information as you feel comfortable providing. Our team is here to support you, answer your questions, and help you explore your options without judgement or pressure.

  You may leave questions blank if you are unsure or would prefer to discuss them with one of our counselors.

  PART 1A

  Section 1: Your Personal Information

  Full Legal Name

  First Middle Last

  Have you ever used any other names? (For example, maiden name, married name, or other legal name.)

  Yes

  No

  If yes, please list:

  Current Address

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

  Date of Birth

  Age

  Place of Birth

  City State / Province / Region AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussian FederationRwandaSaint 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 TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country

  Social Security Number

  If available; may be provided securely at a later time.

  Cell Phone Number

  Is it okay for us to send you text messages?

  Yes

  No

  Is it okay for us to leave you a voicemail?

  Yes

  No

  Email Address

  What is the safest or best way for us to contact you?

  Phone Call

  Text

  Email

  Other

  Other (please specify)

  Marital Status

  SingleMarriedSeparatedDivorcedWidowedIn a RelationshipOther

  Do you have a valid form of identification?

  Yes

  No

  Do you currently have health insurance?

  Yes

  No

  Unsure

  If available, please upload a copy of your identification and/or health insurance card. (Optional)

  Drop files here or Select files

  Max. file size: 512 MB.

  How would you describe your race and/or ethnic background?

  Do you have any Native American or Alaska Native heritage?

  Yes

  No

  Unsure

  If yes, please provide any known tribal affiliation:

  Section 2: Your Family and Background

  Do you have any other children?

  Yes

  No

  If yes, how many and what are their ages?

  Have you ever made an adoption plan for another child?

  Yes

  No

  If yes, please share any information you feel comfortable providing:

  Have you spoken with any other adoption agencies, attorneys, or counselors about adoption for this child?

  Yes

  No

  If yes, please explain:

  Section 3: Biological Family Health History

  The following questions help us better understand your child’s biological family health history. Please share what you know. It is okay if you do not have information about the biological father or other family members. Are you aware of any history of the following conditions in yourself, your child’s biological father, or either biological family? Please indicate the family member(s) affected and share any additional information you know.

  Anxiety

  Family member(s) affected and any additional information you know

  Depression

  Family member(s) affected and any additional information you know

  Bipolar Disorder

  Family member(s) affected and any additional information you know

  Schizophrenia or Schizoaffective Disorder

  Family member(s) affected and any additional information you know

  Autism Spectrum Disorder

  Family member(s) affected and any additional information you know

  Other Mental Health or Developmental Conditions

  Family member(s) affected and any additional information you know

  Is there any known history of alcohol or substance use concerns in either biological family?

  Yes

  No

  Unsure

  If yes, please explain:

  Have you or your child’s biological father ever received inpatient or outpatient treatment for mental health or substance use concerns?

  Yes

  No

  Unsure

  If yes, please describe, including approximate dates if known:

  Is there any additional medical, mental health, or family history you would like us to know about?

  Section 4: Your Child’s Basic Information

  Child’s Full Name

  Child’s Date of Birth

  Child’s Sex Assigned at Birth

  FemaleMaleOther

  Child’s Race/Ethnicity

  Child’s Birth Weight and Length

  Child’s Current Weight and Length

  If known

  Where was your child born? Hospital Name

  Hospital City

  Hospital State

  Does your child have a Social Security number?

  Yes

  No

  Unsure

  Do you have your child’s Social Security card?

  Yes

  No

  Do you have a copy of your child’s birth certificate?

  Yes

  No

  PART 1B

  Section 5: Pregnancy and Birth History

  Did you receive prenatal care during your pregnancy?

  Yes

  No

  If yes, please provide the name of your doctor or medical practice:

  Were there any complications during your pregnancy, labor, or delivery?

  Yes

  No

  Unsure

  If yes, please explain:

  Was your baby exposed to any alcohol, drugs, or medications during pregnancy?

  Yes

  No

  Unsure

  If yes, please describe:

  Did your baby experience any withdrawal symptoms or other medical concerns related to prenatal exposure?

  Yes

  No

  Unsure

  If yes, please explain:

  Did your baby spend any time in the Neonatal Intensive Care Unit (NICU)?

  Yes

  No

  If yes, how long and for what reason?

  Section 6: Your Child’s Medical Information

  Does your child have any known medical conditions, allergies, or special medical needs?

  Yes

  No

  Unsure

  If yes, please describe:

  Is your child currently taking any medications or using any special medical equipment?

  Yes

  No

  If yes, please describe:

  What is your child’s pediatrician’s name and office address?

  Has your child seen a pediatrician since birth?

  Yes

  No

  If yes, when was the most recent visit?

  Do you have any concerns about your child’s overall health, growth, or development?

  Yes

  No

  If yes, please explain:

  Section 7: Department of Children and Families (DCF) Involvement

  Is the Department of Children and Families (DCF) or another child welfare agency currently or previously involved with your family?

  Yes

  No

  Unsure

  If yes, please describe the nature of their involvement:

  Is there currently an open DCF or child welfare case involving your child?

  Yes

  No

  Unsure

  Has DCF or another agency been granted custody or guardianship of your child?

  Yes

  No

  Unsure

  If applicable, please provide the name and contact information of your DCF or child welfare social worker:

  Section 8: Your Child’s Daily Life

  Tell us about your child.

  We’d love to learn about their personality, temperament, routines, likes, dislikes, and anything that makes them special.

  How is your child currently fed?

  Breast Milk

  Formula

  Both

  Other

  If formula-fed, what brand and type of formula does your child use?

  Where is your child currently living?

  Who currently provides day-to-day care for your child?

  Who, if anyone, helps you care for your child?

  Section 9: Biological Father and Caregiving Information

  Is your child’s biological father involved in their care?

  Yes

  No

  Unsure

  If yes, please describe:

  Is your child’s biological father aware that you are considering adoption?

  Yes

  No

  Unsure

  Is your child’s biological father listed on the birth certificate?

  Yes

  No

  Unsure

  Has anyone other than you been granted legal custody or guardianship of your child?

  Yes

  No

  Unsure

  If yes, please explain:

  Has anyone else been caring for your child on a regular basis?

  Yes

  No

  If yes, please describe:

  Section 10: Considering Adoption

  What has led you to consider adoption for your child?

  What does adoption mean to you?

  What qualities would you hope to find in an adoptive family for your child?

  Submit