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?

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Internet Search
Facebook
Instagram
YouTube
Mobile App
Internet Ad
Newspaper
Yellow Pages
Referred by friend
Other
How did you first contact us?

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By Phone
By Chat Line
First Name *
Middle Name
Last Name *
Maiden Name
Email
Phone Number

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Current Address Info
Current Address
Current Address City
Current Address State *

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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Current Address Zip
Current Address County
What address is this?

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Permanent
Temporary
Parents
Boyfriend
Friend
Phone Number at this address

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Please enter a valid phone number.
Are you a US Citizen?

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Yes
No
Social Security Number
What is your Birthday?

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Month
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Day
Area code cannot start with 0 or 1.
Year
Your birth City & State
What is your religion?

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None
Christian
Islam
Hindu
Buddhism
Mormon
Amish
Mennonite
Jehovah
Jewish
What is your marital status?

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Married
Single
Other
Highest level of education?

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None
High School
Trade School
College
Post College
Have you been arrested?

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Yes
No
Have you ever been convicted of a felony?

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Yes
No
Have you ever been reported for child abuse?

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Yes
No
Are you currently working with another Adoption Agency and/or matched with another Adoptive Family?

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Yes
No

Physical Information
What Race are you?

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Caucasian
Caucasian / African American
Caucasian / Hispanic
Caucasian / Asian
African American
African American / Hispanic
African American / Asian
Hispanic
Hispanic / Asian
Asian
What is your complexion?

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Normal
Fair
Olive
Tan
Dark
Are you Native American?

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Yes
No
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

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Black
Brown
Blonde
Red
Eye color

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Brown
Hazel
Blue
Green

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

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Yes
No
Not Sure
Name

First Name Last Name
His Cell Phone Number

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Please enter a valid phone number.
Is he a US Citizen?

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Yes
No
Not Sure
What Race is the Birthfather

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Caucasian
Caucasian / African American
Caucasian / Hispanic
Caucasian / Asian
African American
African American / Hispanic
African American / Asian
Hispanic
Hispanic / Asian
Asian
Is the Birthfather Native American?

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Yes
No
Not Sure
Are you married to the Birthfather?

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Yes
No
Do you and the Birthfather live together?

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Yes
No
Are you certain the Birthfather is the biological father?

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Yes
No
Have you told the Birthfather you are pregnant?

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Yes
No
Has the Birthfather acknowledged that he is the biological father?

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Yes
No
Does the Birthfather know you intend to place the child for adoption?

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Yes
No
Is the Birthfather willing to agree to the adoption and terminate his parental rights?

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Yes
No

Pregnancy Information
What is your due date?

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Month
Area code cannot start with 0 or 1.
Day
Area code cannot start with 0 or 1.
Year
Date
What is the baby's gender?

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Boy
Girl
Unknown
Was the intercourse in which conception occurred consensual?

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Yes
No
Has there been any sexual or physical abuse during this pregnancy?

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Yes
No
Have you had any abortions?

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Yes
No
Have you had any miscarriages?

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Yes
No
Have you had any stillbirths?

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Yes
No
Have you had any prenatal care?

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Yes
No
Are you currently seeing a Doctor or Obstetrician?

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Yes
No
Have you told your friends about your intentions to place your child for adoption?

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Yes
No
Have you told your family about your pregnancy?

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Yes
No
Have you told your family about your intentions to place your child for adoption?

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Yes
No
Does your family support your decision?

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Yes
No
Do you live with your family?

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Yes
No
Do you have state provided medical coverage?

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Yes
No
Do you have other medical insurance?

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Yes
No

Adoption Preferences
Preferred marital status of adoptive family

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No preference
Married
Single
Preferred age of adoptive family

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No preference
20-30
30-40
40+
Preferred race of adoptive family

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No Preference
Caucasian
African American
Hispanic
Asian
Preferred religion of adoptive family

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No preference
Christian
Islam
Hindu
Buddhism
Mormon
Amish
Mennonite
Jehovah
Jewish
How many children do you prefer the adoptive family have?

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No preference
None
Single Child
Multiple Children
Are you open to a same sex couple?

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Yes
No
Are you open to a family that smokes cigarettes?

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No preference
Yes
No
Case by Case
Are you open to a family that has been treated for alcohol abuse?

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No preference
Yes
No
Case by Case
Are you open to a family that has been treated for drug abuse?

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No preference
Yes
No
Case by Case
Would you like the adoptive parents to be present at the hospital during your hospital stay?

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No preference
Yes
No
Case by Case
During the pregnancy, how much contact with the adoptive parents would you feel comfortable with?

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No Contact
Phone Calls
Personal Visits
After the birth, what level of contact would you like with the adoptive family?

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No Contact
Letters and Pictures
Personal Visits

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?

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Yes
No
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) *

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Yes
No
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) *

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I decline to receive counseling at this point
I would like counseling to be provided

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) *

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Yes
No
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) *

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Yes
No

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) *

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I accept this Agreement
I do not accept this Agreement
Signature (REQUIRED). If you are on a smartphone or digital device, you can use your finger or stylus. *

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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