Birth Mother Information FormPlease enable JavaScript in your browser to complete this form.****Please Complete ALL Sections of this Form.****If you don’t know the information requested, write "unknown" in the space provided. If the information requested does not apply to your situation, write "N/A" (not applicable) in the space provided.Date *How were you referred to the Adoption Alliance? *Estimated Due Date *Gender of Child *Gender of ChildFemaleMaleUnknownTwinsCONTACT INFORMATIONName *FirstMiddleLastMaiden Name *Date of Birth *Place of Birth *Cell Phone # *Phone # (Other)Email *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security Number *Driver's License # and State Issued *EMERGENCY CONTACT INFORMATIONName *FirstLastPhone # *Relationship to Client *PHYSICAL DESCRIPTION / CITIZENSHIPHeight *Usual Weight *Eye Color *BlueBrownGreenHazelSkin Complexion *FairMediumOliveBrownBlackHair Color *BlondeBrunetteBlackRedHair Texture *StraightCurlyWavyEthnicity (check all that apply) *CaucasianHispanicAsianAfrican AmericanNative American IndianOtherIf "OTHER", Please Explain *Are you a Citizen of the United States? *YESNOIf not a US Citizen, What is your Citizenship? *GENERAL QUESTIONSHighest grade completed in school *Are you currently employed? *YESNOIf YES, Where? *Are you religious? *YESNOIf YES, What is your Religion? *Where you Adopted? *YESNOIf YES, Date of Adoption *If YES, Agency or Attorney's Name *What are your hobbies and talents? *Favorite Food *Favorite Color *Favorite Place *Favorite Type of Music *Favorite TV Show *Favorite Movie *Favorite Class in School *INDIAN HERITAGEAny child having substantial Native American Indian heritage, must by law have a release from their tribe before being placed for adoption. Consequently, if you are a member of an Indian tribe, the Adoption Alliance may need to contact the appropriate tribe.Indian Heritage *To my knowledge, there is NO American Indian Heritage in my family.I have SOME American Indian Heritage, but I am not a registered member of a tribe.Yes, I AM a registered member of a Native American Indian Tribe.Tribe Name *Card # *INSURANCE / MEDICAIDDo you have Medicaid? *YesNoIf YES, Medicaid # *Do you have Private Insurance? *YesNoWill it cover your Pregnancy? *YesNoName of Carrier *Policy # *Group # *MARITAL STATUSMarital Status *SingleMarriedDivorcedWidowedHusband's Name *Husband's Phone # *Date of Marriage *Ex-Husband's Name *Ex-Husband's Phone # *Date of Divorce *BIRTH FATHER INFORMATIONIn what State was this pregnancy conceived? *Do you know the identity of the father of your current pregnancy? *YESNOIf YES, What is his full name? *Is this man the only possible father of this child? *YESNODo you live with the father of this child? *YESNOIs the father aware of this pregnancy? *YESNOIs the father aware of the adoption plan? *YESNOIs the father supportive of the adoption plan? *YESNOUNKNOWNPREGNANCY HISTORYHave you had prenatal care during this pregnancy? *YESNOOBGYN or ClinicDoctor's Name *Phone # *AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateHave you had ANY complications during this pregnancy? *YESNOHave you had ANY complications during any other pregnancy? *YESNOHave you been involved in any accidents during this pregnancy? *YESNOHave you been arrested during this pregnancy? *YESNOAre you currently on parole or probation? *YESNOHas anyone physically abused you during this pregnancy? *YESNOHave you worked with another adoption agency during this pregnancy? *YESNOIf YES, which one? *Have you worked with another adoption agency during a PRIOR pregnancy? *YESNOIf YES, which one? *Have you ever had any history or involvement with Child Protective Services (CPS)? *YESNOMEDICAL HISTORYAlcohol use *NoneDuring this PregnancyPrior to this PregnancyTobacco / Nicotine use *NoneDuring this PregnancyPrior to this PregnancyPrescription Medication use *NoneDuring this PregnancyPrior to this PregnancyIf Yes during pregnancy, provide a list of prescription medication *If Yes prior to pregnancy, provide a list of prescription medication *Drug use *NoneDuring this PregnancyPrior to this PregnancyIf Yes during pregnancy, provide a list of drugs used *If Yes prior to pregnancy, provide a list of drugs used *Have you had a diagnosis of a STD or STI during this pregnancy? *YESNOSTD or STI during this pregnancy. (CHECK ALL THAT APPLY) *ChlamydiaGenital WartsGonorrheaHerpesHepatits CHIV / AIDSSyphilisOtherHave you had a diagnosis of a STD or STI prior to this pregnancy? *YESNOSTD or STI prior to this pregnancy. (CHECK ALL THAT APPLY) *ChlamydiaGenital WartsGonorrheaHerpesHepatits CHIV / AIDSSyphilisOtherPlease provide any information on significant medical history or conditions for you or your immediate family.ADOPTION PLAN PREFERENCESWhat type of adoption plan are you considering? *OpenSemi-OpenClosedUnknownWould you like to select the adoptive family? *YESNOUNKNOWNWould you like phone calls with the adoptive family? *YESNOUNKNOWNWould you like to meet the adoptive family? *YESNOUNKNOWNDo you have a preference concerning the religious faith of the adoptive parents? *YESNOIf YES, What Religion? *COUNSELINGCounseling is available to you concerning your adoption plan during your pregnancy, after the birth, and during the post-partum period.Do you feel you currently need counseling concerning your adoption plan? *YESNOFORM SUBMISSIONI have voluntarily provided the information herein. I have completed the forms as accurately as possible. I have not intentionally omitted any information. THE ADOPTION ALLIANCE may share with the prospective adoptive parents of my child and/or their legal representative:(1) the information in this form, (2) medical and psychological information (past and present), (3) information concerning me, including lab results, medical charts, counseling notes, progress notes and/or verbal information received from my physicians, counselors or hospitals. I understand that where necessary, this information will be included with material sent to the Interstate Compact offices, in compliance with the laws regarding the Interstate Placement of Children. I understand all documentation concerning the adoption plan for this child will may be filed with the District Court in San Antonio, Bexar County, Texas.Form Completed by: *Signature *Clear SignatureSubmit