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Birth Mother Questionnaire

If you are interested in adoption, please fill out the confidential form below and e-mail it to us. Your form will not be shared with anyone without your knowledge. We will call or e-mail you to acknowledge its receipt and discuss further plans with you.

We will work very actively together with you on your behalf once you have indicated to us that you would like our involvement or we can refer you to appropriate resources with whom we have worked and know of their expertise and care.

Legal name (First, middle, last)

Address

Street

Apt. #

City

State

Zip

Phone

home

cell

work

Date of birth:

Place of birth

Marital Status:

Single		Never married		Married		Divorced
						Date of divorce

Race/ethnic background

Religion

Any Native American ancestry?

yes

If yes, please list tribe/s

Degree of Native American ancestry? Mother/father/grandparents

Birth father’s name

Is he aware of your pregnancy?

yes

Is he willing to place this child for adoption?

yes

uncertain

Is there more than one possible birth father?

yes

Please discuss below what type of family would be best suited for your child? (e.g. cultural and religious background; two parent family, single female or male, gay/lesbian couple; educational background and standards; have children or not; outdoors type; like to travel; love animals……. )

Would you prefer to have your adoption open or closed?

(“Open” typically means you chose the adoptive family and have the option to meet with them and to maintain some continuing contact with them after placement, to be determined by both you and the family. Continuing contact most commonly means receiving pictures and letters for a specified amount of time. "Closed" typically means you may or may not chose the adoptive family. It's up to you. You may not want to meet them, nor even know anything about them. Sometimes birth mothers think they want a closed adoption, and later wish to make it more open. You need to keep your wishes current with your contact person. Some adoptive families prefer and "open" adoption while others prefer a "closed" adoption. They need to know your choice prior to being matched.)