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.

CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

PHYSICAL DESCRIPTION / CITIZENSHIP

GENERAL QUESTIONS

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.

INSURANCE / MEDICAID

MARITAL STATUS

BIRTH FATHER INFORMATION

PREGNANCY HISTORY

MEDICAL HISTORY

ADOPTION PLAN PREFERENCES

COUNSELING

Counseling is available to you concerning your adoption plan during your pregnancy, after the birth, and during the post-partum period.

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.