Birthmother Application | Give Your Child Up for Adoption

Completing this application should take between 5-10 minutes. Please make sure to answer as many questions as you can. Make sure to hit the “Submit Application Now” button at the end.

Step 1
About Yourself
Step 2
Physical Information
Step 3
About the Birthfather
Step 4
Pregnancy Information
Step 5
Adoption Preferences
Step 6
Expenses
Step 7
Authorizations
Step 8
Agreement & Signature

About Information
How did you hear about our agency?
How did you first contact us?
First Name *
Middle Name
Last Name *
Maiden Name
Email
Phone Number
Current Address Info
Current Address
Current Address City
Current Address State *
Current Address Zip
Current Address County
What address is this?
Phone Number at this address
Please enter a valid phone number.
Are you a US Citizen?
Social Security Number
What is your Birthday?

Month Day Year
Your birth City & State
What is your religion?
What is your marital status?
Highest level of education?
Have you been arrested?
Have you ever been convicted of a felony?
Have you ever been reported for child abuse?
Are you currently working with another Adoption Agency and/or matched with another Adoptive Family?

Physical Information
What Race are you?
What is your complexion?
Are you Native American?
If Yes, what percentage Native American?
What Native American tribe?
What is your Native American tribe roll number?
Height (example: 5ft 6in)
Pre-pregnancy weight
Current weight
Natural hair color
Eye color

Tell us about the Birthfather
Do you know who the Birthfather is?
Name

First Name Last Name
His Cell Phone Number
Please enter a valid phone number.
Is he a US Citizen?
What Race is the Birthfather
Is the Birthfather Native American?
Are you married to the Birthfather?
Do you and the Birthfather live together?
Are you certain the Birthfather is the biological father?
Have you told the Birthfather you are pregnant?
Has the Birthfather acknowledged that he is the biological father?
Does the Birthfather know you intend to place the child for adoption?
Is the Birthfather willing to agree to the adoption and terminate his parental rights?

Pregnancy Information
What is your due date?

Month Day Year
Date
What is the baby's gender?
Was the intercourse in which conception occurred consensual?
Has there been any sexual or physical abuse during this pregnancy?
Have you had any abortions?
Have you had any miscarriages?
Have you had any stillbirths?
Have you had any prenatal care?
Are you currently seeing a Doctor or Obstetrician?
Have you told your friends about your intentions to place your child for adoption?
Have you told your family about your pregnancy?
Have you told your family about your intentions to place your child for adoption?
Does your family support your decision?
Do you live with your family?
Do you have state provided medical coverage?
Do you have other medical insurance?

Adoption Preferences
Preferred marital status of adoptive family
Preferred age of adoptive family
Preferred race of adoptive family
Preferred religion of adoptive family
How many children do you prefer the adoptive family have?
Are you open to a same sex couple?
Are you open to a family that smokes cigarettes?
Are you open to a family that has been treated for alcohol abuse?
Are you open to a family that has been treated for drug abuse?
Would you like the adoptive parents to be present at the hospital during your hospital stay?
During the pregnancy, how much contact with the adoptive parents would you feel comfortable with?
After the birth, what level of contact would you like with the adoptive family?

Expense Affidavit

If you believe that you may need financial assistance during your pregnancy, this form must be completed. We can not guarantee that your state laws will permit the opportunity for you to receive aid, or for the amount you are requesting.
Will you need help with living and pregnancy-related expenses?
Expenses

What monthly expenses will you need help with (enter amounts)
Monthly Rent
Monthly Phone Expense
Monthly Utilities
Monthly Food Expenses
Monthly Transportation Expenses
Monthly Household Expenses
If you are in need of maternity clothes, how much will they cost?
Other Monthly Expenses (enter amount)
What are these Other Monthly Expenses for?
I understand that it is illegal to receive financial benefits from any prospective adoptive family without the intention of completing an adoption. I further understand that it is illegal to receive financial benefits from more than one prospective adoptive family and/or adoption entity at the same time.
I hereby declare that all information on this "Expense Affidavit" is true and correct. (REQUIRED) *
Counseling Affidavit

Abby’s One True Gift Adoptions is a licensed child placing agency and is required by state law to notify all prospective Birthparents that counseling is available.Iowa statute 108.9(2) Services to birth families. An agency which offers services to birth parents who are considering relinquishing a child for adoption shall provide a minimum of three hours of counseling, or any additional hours of counseling necessary to assist the parents in making an informed decision regarding their child’s adoption, consistent with the child’s best interest. The counseling of the birth parents shall begin when the birth parents begin the intake process.
In accordance with agency licensing requirements, please choose (1) one of the following: (REQUIRED) *

Criminal Background Search Authorization

Abby’s One True Gift Adoptions is a licensed child placing agency and is required by the State of Iowa to EITHER, conduct a criminal background search on all prospective birthmothers OR, receive notification from the prospective birthmother that they do not wish to have a criminal background search conducted by the agency. A criminal background search is not a requirement by federal adoption laws and if you elect to not allow Abby’s One True Gift Adoptions to conduct a criminal background search, it will not prohibit you from placing your child for adoption nor will it prohibit you from working with our agency to achieve your adoption goals.
I hereby give authorization to allow a Criminal Background search to be conducted. (REQUIRED) *
Medical Record Authorization

Per the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I hereby authorize any medical practitioner or facility or related entity to give Abby’s One True Gift Adoptions Inc. any of the following;Verification of any documentation presented to them by me which substantiates my current condition as it relates to pregnancy.Medical information, records and data about me related to pregnancy.The entire medical file for the last three years not excluding; medical information, records and data, alcohol and drug use and/or abuse, and drugs prescribed.Information, records and data about me relating to mental illness, other than psychotherapy notes.
I agree to allow any medical facility to release above mentioned information to Abby's One True Gift Adoptions. (REQUIRED) *

Agreement

ADOPTION: I understand that Abby’s One True Gift Adoptions Inc. will process a legal and ethical adoption for me, my child (children), and the family I select. I understand I have the right to select or reject any adoptive parents, and that Abby’s One True Gift Adoptions Inc. does not make decisions concerning my selection of adoptive parents unless I specifically state otherwise. REPRESENTATION: I am not currently associated with any other entity, formally or informally, who might assist me to locate a family to adopt my child (children). I am not currently communicating with any prospective adoptive parents concerning the adoption of my child (children). I understand that it is illegal to arrange with multiple prospective parents at the same time in the interest of adopting my child and/or receive financial benefits from multiple prospective families at the same time during my pregnancy. WAIVER OF CONFIDENTIALITY: I hereby authorize Abby’s One True Gift Adoptions Inc. and any of its representatives to share all information provided by me with any prospective adoptive parents who may be interested in adopting my child (children), or any representative acting on their behalf, or on my behalf, and with any professional otherwise connected with the adoption plan. FINANCIAL ASSISTANCE: I understand that dependent on the laws of my state and the state the adoptive parents reside in, I may not be permitted to receive financial assistance from adoptive parents. I understand that it is illegal to receive financial benefits from any prospective adoptive family without the intention of completing an adoption. ACKNOWLEDGEMENT: I acknowledge that all information provided (written and/or spoken) to Abby’s One True Gift Adoptions is factual and accurate to the best of my knowledge.
By agreeing, I acknowledge that I have read this Agreement in full and hereby accept it’s conditions. (REQUIRED) *
Signature (REQUIRED). If you are on a smartphone or digital device, you can use your finger or stylus. *

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I agree to these terms and conditions. I authorize the collection and storing of this sensitive data.
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About Information

Current Address Info

Physical Information

Tell us about the Birthfather

Pregnancy Information

Adoption Preferences

Expense Affidavit

Expenses

Counseling Affidavit

Criminal Background Search Authorization

Medical Record Authorization

Agreement