Birthmother Application | Give Your Baby Up for Adoption

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Pregnant?

Birthmother Application

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

How did you hear about our agency?

How did you first contact us?

First Name *

Middle Name *

Last Name *

Maiden Name*

Phone Number

Current Address

Current Address City

Current Address State*

Current Address Zip

Current Address County

What address is this?

Phone Number at this address

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?

First Name

Last Name

His Cell 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

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?

Adoption Preferences

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.
TERMS AND CONDITIONS: I agree to these terms and conditions. I authorize the collection and storing of this sensitive data.

By agreeing, I acknowledge that I have read this Agreement in full and hereby accept it’s conditions. (REQUIRED) *

Sign Here*

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