****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.
How were you referred to the Adoption Alliance? * Gender of Child * Gender of Child Female Male Unknown Twins CONTACT INFORMATION Maiden Name * Place of Birth * Cell Phone # * Phone # (Other) Email * Social Security Number * Driver's License # and State Issued * EMERGENCY CONTACT INFORMATION Phone # * Relationship to Client * PHYSICAL DESCRIPTION / CITIZENSHIP Height * Usual Weight * Ethnicity (check all that apply) * If "OTHER", Please Explain * Are you a Citizen of the United States? * If not a US Citizen, What is your Citizenship? * GENERAL QUESTIONS Highest grade completed in school * Are you currently employed? * If YES, Where? * If YES, What is your Religion? * If 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 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.
Tribe Name * Card # * INSURANCE / MEDICAID If YES, Medicaid # * Do you have Private Insurance? * Will it cover your Pregnancy? * Name of Carrier * Policy # * Group # * MARITAL STATUS Husband's Name * Husband's Phone # * Ex-Husband's Name * Ex-Husband's Phone # * BIRTH FATHER INFORMATION In what State was this pregnancy conceived? * Do you know the identity of the father of your current pregnancy? * If YES, What is his full name? * Is this man the only possible father of this child? * Do you live with the father of this child? * Is the father aware of this pregnancy? * Is the father aware of the adoption plan? * Is the father supportive of the adoption plan? * PREGNANCY HISTORY Have you had prenatal care during this pregnancy? * OBGYN or Clinic Doctor's Name * Phone # * 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? * If YES, which one? * Have you worked with another adoption agency during a PRIOR pregnancy? * If YES, which one? * Have you ever had any history or involvement with Child Protective Services (CPS)? * MEDICAL HISTORY Prescription Medication use * If Yes during pregnancy, provide a list of prescription medication * If Yes prior to pregnancy, provide a list of prescription medication * If 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? * STD or STI during this pregnancy. (CHECK ALL THAT APPLY) * Have you had a diagnosis of a STD or STI prior to this pregnancy? * STD or STI prior to this pregnancy. (CHECK ALL THAT APPLY) * 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? * Would you like to select the adoptive family? * Would you like phone calls with the adoptive family? * Would you like to meet the adoptive family? * Do you have a preference concerning the religious faith of the adoptive parents? * If YES, What Religion? * 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: *