Birth Parents - Contact Pregnancy Counselor

Birth Parents Contact Form

Please fill these form out in as much detail as possible. All information is CONFIDENTIAL. The decision to place your baby for adoption is not an easy one to make on your own. It can be very difficult, and even painful. We understand that, and we also commend you for making the choice to put your baby’s needs before your own. Our trained staff and social workers will help you work through your pain, and approach it in light of the gift you are giving someone else. Our organization also provides professional counseling at no cost to the birth parents. Required *
* First Name:
Last Name:
*Email Address:
*Phone Number:
Night Phone Number:
Best time to reach you:
Address:
*City:
*State:
Zip:
Country:
Referred By:
*Can we call and leave a message?	Yes No
* Explain:
* Birthmothers Age:
* Birthmothers Due Date:
*Have you had prenatal care?	Yes No
*Explain:
*Do you have medical insurance?	Yes No
Birthmother's Marital History:
(If applicable please specify date of marriage, divorce etc.)
* Birthfather's Name:
Birthfather's Age:
*Does the Birthfather know you are planning to do an adoption?	Yes No
*Is the birthfather supportive of an adoption?	Yes No
Please describe your relationship with the birthfather:
*Baby Ethnicity:
Have you placed a child for adoption before?	Yes No
*Your feelings about adoption are:
What are you looking for when selecting adoptive parents?
Are your parents aware of your adoption plan?	Yes No
Do you have family/friends support?	Yes No

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