Birth Parent Intake Form - The Adoption Alliance

Birth Mother Information 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 *

CONTACT INFORMATION

Name *

First

Middle

Last

Maiden Name *

Date of Birth *

Place of Birth *

Cell Phone # *

Phone # (Other)

Email *

Address *

Address Line 1

City

State

Zip Code

Social Security Number *

Driver's License # and State Issued *

EMERGENCY CONTACT INFORMATION

Name *

First

Last

Phone # *

Relationship to Client *

PHYSICAL DESCRIPTION / CITIZENSHIP

Height *

Usual Weight *

Eye Color *

Blue
Brown
Green
Hazel

Hair Color *

Blonde
Brunette
Black
Red

Hair Texture *

Straight
Curly
Wavy

Are you a Citizen of the United States? *

GENERAL QUESTIONS

Highest grade completed in school *

Are you currently employed? *

Are you religious? *

Where you Adopted? *

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 HERITAGE

Any 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.

INSURANCE / MEDICAID

Do you have Medicaid? *

Do you have Private Insurance? *

MARITAL STATUS

Marital Status *

Single
Married
Divorced
Widowed

BIRTH FATHER INFORMATION

In what State was this pregnancy conceived? *

Do you know the identity of the father of your current pregnancy? *

PREGNANCY HISTORY

Have you had prenatal care during this pregnancy? *

Have you had ANY complications during this pregnancy? *

Have you had ANY complications during any other pregnancy? *

Have you been involved in any accidents during this pregnancy? *

Have you been arrested during this pregnancy? *

Are you currently on parole or probation? *

Has anyone physically abused you during this pregnancy? *

Have you worked with another adoption agency during this pregnancy? *

Have you worked with another adoption agency during a PRIOR pregnancy? *

Have you ever had any history or involvement with Child Protective Services (CPS)? *

MEDICAL HISTORY

Alcohol use *

None
During this Pregnancy
Prior to this Pregnancy

Tobacco / Nicotine use *

None
During this Pregnancy
Prior to this Pregnancy

Prescription Medication use *

None
During this Pregnancy
Prior to this Pregnancy

Drug use *

None
During this Pregnancy
Prior to this Pregnancy

Have you had a diagnosis of a STD or STI during this pregnancy? *

Have you had a diagnosis of a STD or STI prior to this pregnancy? *

Please provide any information on significant medical history or conditions for you or your immediate family.

ADOPTION PLAN PREFERENCES

What type of adoption plan are you considering? *

Open
Semi-Open
Closed
Unknown

Would you like to select the adoptive family? *

YES
NO
UNKNOWN

Would you like phone calls with the adoptive family? *

YES
NO
UNKNOWN

Would you like to meet the adoptive family? *

YES
NO
UNKNOWN

Do you have a preference concerning the religious faith of the adoptive parents? *

COUNSELING

Counseling 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? *

FORM SUBMISSION

I 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 *

****Please Complete ALL Sections of this Form.****