BIRTH MOM INTAKE FORM

This information is sent to Roxanne – Birth Mom Support Service and Outreach Director who will complete the intake and assessment with you, provide education, guidance and support to on a regular basis throughout your pregnancy.  

The Birth Mom Outreach Director will help to coordinate contact between birth parent and adoptive family throughout and after pregnancy and other tasks as assigned. 

CONTACT US DIRECTLY: 

"*" indicates required fields

BIRTH MOTHER INFORMATION

Name*
Maiden Name or Any other name you've gone by (if applicable)
Adoption Services Available (Check All That Apply to You)
Is it OK to text this number?*
Address
Do you have Medicaid or Private Insurance?
MM slash DD slash YYYY

BIRTH MOTHER PHYSICAL CHARACTERISTICS

Race

Ex: You may be Caucasian with Irish/Italian heritage
Complexion

Hair Color

Glasses/Contacts?
Are you a registered member of an American Indian Tribe or Alaskan Village?

EDUCATION & WORK HISTORY

Number of Years Attended
Grade School
High School
College
 
Do you work?
Address of Present Employer:

MARITAL STATUS

Are you?

If Married, Husband Name:
Address
Date of Birth
Date of Marriage
Is he aware of your pregancy?
Is he the father of this baby?
Does he support an adoption plan?
Does he live with you?
Does he financially support you?
Is he in the military?
Are you currently in a relationship with a man other than your husband?

ABOUT YOUR CHILDREN

Complete one row per child
First Name
Gender
Age
Any Health Concerns?
Living/Deceased, Custody/Adoption
 
Include any children previously placed for adoption. If any child is deceased, please provide cause of death.

ABOUT YOUR FAMILY

Mother
First Name
Age
Occupation
Hobbies
 
Father
First Name
Age
Occupation
Hobbies
 
Maternal Grandmother
First Name
Age
Occupation
Hobbies
 
Maternal Grandfather
First Name
Age
Occupation
Hobbies
 
Paternal Grandmother
First Name
Age
Occupation
Hobbies
 
Paternal Grandfather
First Name
Age
Occupation
Hobbies
 
Sibling
First Name
Age
Occupation
Hobbies
 
Sibling
First Name
Age
Occupation
Hobbies
 
Sibling
First Name
Age
Occupation
Hobbies
 
Sibling
First Name
Age
Occupation
Hobbies
 

IDENTIFICATION

Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
    Drop files here or
    Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

      ABOUT YOUR PREGNANCY

      Due Date
      Gender of Baby
      Race of Baby

      Do you have Medicaid?
      Do you have private insurance?
      Doctor or Clinic Address:
      Hospital Address:
      Have you experienced any sexual or physical abuse during pregnancy?
      Have you been in a car accident during this pregnancy?
      Have you experienced any complications this pregnancy?
      Have you had X-Ray, electrocardiogram or radiation exposure during pregnancy?
      Have you had any of the following conditions during this pregnancy?
      Check all that apply

      MEDICATIONS AND SUBSTANCES

      What medications or substances were used during this pregnancy?
      Cigarettes
      Alcohol
      Marijuana
      Methamphetamine
      Cocaine/Crack
      Huffing
      Heroine
      Ecstasy
      Methadone
      Subutex
      Suboxone
      Stimulants
      Depressants
      Diet Pills
      Hormones
      Cortisone (ATCH), etc.
      Barbiturates
      Lithium
      Accutane

      YOU & YOUR FAMILY'S HEALTH HISTORY

      Have you or a family member had any of the below congenital impairments?
      Do you or any family members have the below allergies?
      Do you or any family members have any of the below eye, ear, or developmental disorders?
      Do you or any family members have any of the below Circulatory Disorders?
      Do you or any family members have any of the below Hormonal Disorders?
      Do you or any family members have any of the below Respiratory Disorders?
      Do you or any family members have any of the below Mental & Behavioral Disorders?
      Do you or any family members have any of the below medical conditions?

      ABOUT YOUR BABY'S FATHER

      If birth father is unavailable to complete this section, please complete it to the best of your knowledge.
      Name
      Address
      MM slash DD slash YYYY
      Is he aware of the pregnancy?
      Are you together as a couple?
      Is he aware of your adoption plans?
      Will he consent to this adoption?
      Does he want to be involved?
      Does he have other children?
      If yes, does he support them?
      Does he work?

      BIRTH FATHER PHYSICAL CHARACTERISTICS

      Race

      Is he a registered member of an American Indian Tribe or Alaskan Village?
      Complexion

      Eye Color

      Hair Color

      Glasses/Contacts

      BIRTH MOTHER HOSPITAL CARE PLAN

      Birthmothers wishes - the birth mother has the right to change these requests. Please try to accommodate her wishes to the extent possible, of course to the approval of the attending physicians and applicable hospital policies.
      Birth Mother's Name
      Date of Birth
      Would you like to see the baby after delivery?
      Would you like to know the sex of the baby?
      Would you like to care for the baby in the hospital?
      Would you like the adoptive couple in the delivery room?
      Would you like the adoptive couple to care for the baby?
      Would you like to be moved from the maternity floor?
      Would you consent to circumcision, if it's a boy?
      Note to hospital staff: If birth mother chooses not to know the sex of the baby, please have a consent to circumcision signed before birth, if possible, to avoid inadvertently disclosing the sex of the baby.
      Would you like your hospital stay kept totally confidential?
      Hospital may release information pertaining to my delivery to my adoption case worker.

      ABOUT YOUR ADOPTION PLAN

      If you choose adoption, what characteristics would you like the adoptive parents to have? This worksheet may help you determine what you are looking for in an adoptive family. Check the box that most closely fits your wishes. If you have other desires, please discuss this with your adoption coordinator.
      Desired Marital Status:
      Desired Family Structure:
      Desired Race of Parents:
      Adoption Status

      COMMUNICATION WITH ADOPTIVE FAMILY

      BEFORE the baby is born, do you want to text with adoptive family?
      BEFORE the baby is born do you want to meet with adoptive family?
      BEFORE the baby is born, do you want to talk with adoptive family on the phone?
      AFTER the baby is born do you want to receive letters and photos?
      AFTER the baby is born do you want to exchange emails?
      AFTER the baby is born do you want face to face visits?

      AFMC does not verify pregnancy of Expectant Mother that visit our site. If an expectant mother contacts us, her information is received by a third party qualified to provide her guidance and support. ALL “vetting” verification of pregnancy are completed by a third party. We network with qualified professionals that we refer expectant mothers to when visiting AFMC site to verify pregnancy and provide case management when needed. AFMC does not employee or contract the professionals we refer expectant mother too. If an expectant mother decides adoption is the right option. Our families will be notified of the available situation. Families will be responsible for covering any fees from the service provider working with the expectant mother.