Adoption Paperwork for Pregnant Women

Providing the Support You Need In Choosing Your Child's Future

Confidentiality Statement
All information you share with us is completely confidential.
We only use this information to assist you in learning more about adoption for your specific situation.

Confidential Adoption Information Questionnaire
for placing a baby for adoption

Please complete as much of this form as you feel comfortable with.

Completing this form does not require that you
complete an adoption plan. It enables us to better help you in your unique situation.

First, The Basics…
Your Full Name
Your Address
City
State
Zip code
Phone number
Cell phone number
Email address
Confidential?	Yes No
May we leave a message?	Yes No
U.S. Citizen?	Yes No
Your Date of Birth
How did you hear about Lifetime?
About Your Adoption Plan…
What type of adoptive family are you looking for?
What are your hopes & dreams for your child?
Does your family know about your pregnancy?
Will they support you in choosing an adoption plan?
Will your friends support you in an adoption plan?
What plans/goals do you have for the next 2 years?
What would make you change your mind & decide to parent?
If you desire ongoing contact after the adoption with the adoptive family, please describe your wishes:
Will you need financial assistance for your pregnancy-related expenses? If yes, please describe:
About Your Health & Pregnancy…
Estimated due date?
Date of last period?
Have you seen a doctor?	Yes No
Have you had an ultrasound?	Yes No
Have you had complications?	Yes No
Baby’s gender, if known?	Boy Girl
Your Doctor’s Information...
Name
City
State
Phone number
Hospital you plan to deliver at:
City
State
Phone number
Do you have insurance?	Yes No
Do you have MediCaid/MediCal?	Yes No
Number of pregnancies you’ve had, including this one?
Any C-sections?	Yes No
Number of miscarriages:
Number of live births:
Number of abortions:
Health Background Please share with us any health issues that you, your baby’s father, or your families may have.
Medications you are taking?
During this pregnancy, have you smoked cigarettes?	Yes No
How much? When?
Used Alcohol?	Yes No
How much? When?
Used Drugs?	Yes No
How much? When?
A Little More About You…
Do you work? If so, what do you do?
Last school attended?
Highest grade completed?
Natural Hair Color?
Eye Color?
Complexion?
Current Weight?
Pre-pregnancy Weight?
Height?
Your Race?
Any Native American Heritage?
Are you legally married?	Yes No
Married to baby’s father?	Yes No
Have you been arrested?	Yes No
If arrests, please explain:
Do you have any children?	Yes No
If yes, do they live with you?	Yes No
What are their ages?
About the Father of Your Baby…
His Name
His Address
City
State
Zip code
Phone number
Cell phone number
U.S. Citizen?	Yes No
His Age or Date of Birth
Does he work? If so, what does he do?
Hair Color?
Eye Color?
Complexion?
Height?
His Race?
Any Native American Heritage?
Does he know you’re pregnant?	Yes No
Does he know you’re considering adoption?	Yes No
Has he helped you financially?	Yes No
Does he wish to meet the adoptive parents?	Yes No
Have you lived with him?	Yes No
Has he acknowledged the child is his?	Yes No
Does he have other children?	Yes No
Does he have a history of drug use?	Yes No
Has he been arrested?	Yes No
If yes, please explain...
Do you believe he is willing to agree to the adoption and sign the necessary legal papers?	Yes No
Other Things You May Wish to Share
Favorite Color?
Favorite Food?
Special Talents?
Favorite Hobby?
Music You Like?
Favorite Movie?
Favorite Pet?
I want to learn to…
One thing I’d like my child to know about me…
One thing I’d like adoptive family to know about me…
My top three adoptive families are...
1st choice
2nd choice
3rd choice
My Open Adoption Plan Open adoption means that you have the opportunity to make choices that affect you. You may want to make these choices or you may prefer to leave them to others. This information will be made available to hospital staff and your chosen family so they are aware of your preferences.
My doctor's name:
Doctor's phone number:
My hospital:
Hospital's phone number:
While in the hospital, I would like...
To see my baby?	Yes No
To hold my baby?	Yes No
To know the gender of my baby?	Yes No
To order my set of newborn photos?	Yes No
A private room, if possible?	Yes No
A non-maternity floor, if possible?	Yes No
The following people can be allowed in the delivery room with me:
The following people can see and/or hold my baby:
Any other special requests:
If possible, I'd like the umbilical cord to be cut by:
At discharge, would you prefer to leave before, after, or at the same time as the adoptive parents and baby?	Before After At the same time

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