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Step
1
of
5
- Step 1
20%
Today's Date
MM slash DD slash YYYY
Expectant Mother's Name
*
First
Last
Do you know who the father is?
*
Yes
No
Expectant Father's Name
*
First
Last
Phone
*
Alternative Phone (optional)
Email
*
Address
(We will not send any mail to this address)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Are you currently working with other adoption agency or attorney?
*
Yes
No
What is the name of the agency or attorney?
*
Do you have medical insurance that covers your pregnancy?
*
Yes
No
Do you have access to a reliable car or public transportation so you can get to your pregnancy, therapy, or adoption related appointments?
*
Yes
No
If you don't, we can arrange for an Uber or case worker to pick you up and drive you to and from your appointments.
Baby's Details
How many months pregnant are you currently?
1
2
3
4
5
6
7
8
9
N/A
How many babies are you expecting?
*
Single Child
Twins
Triplets
What is your due date?
*
MM slash DD slash YYYY
Estimated is okay
Baby's Gender
*
Girl
Boy
Unknown
Are your twins Fraternal or Identical?
*
Fraternal
Identical
Unknown
What is the gender of Baby A
*
Boy
Girl
Unknown
What is the gender of Baby B
*
Boy
Girl
Unknown
What is the gender of Baby C
*
Boy
Girl
Unknown
Expectant Mother Details
How would you describe yourself to someone that has never met you?
(Example: kind, loving, nervous, hard-worker, intelligent, outgoing, loyal, loving, funny, witty, etc)
Your Date of Birth
*
MM slash DD slash YYYY
Relationship Status
*
Single (not with father)
Together with father (just not married)
Engaged
Married
In a Domestic Partnership
List any current children you have (skip if not applicable)
Child's Name (optional)
Age
List any health related conditions or concerns
Expectant Mother's Race/Ethnic Background (select all that apply)
*
Asian
Black/African-American
Hispanic/Latino (Non-white)
Hispanic/Latino (white)
Middle Eastern
Native American
Pacific Islander
White/Caucasian
Other Not Listed
Expectant Mother's Natural Hair Color
*
Blonde
Brown
Black
Red
Expectant Mother's Eye Color
*
Grey
Green
Blue
Brown
Hazel
Black
Expectant Mother's Height
*
Please select
4 feet 9 inches
4 feet 10 inches
4 feet 11 inches
5 feet 0 inches
5 feet 1 inches
5 feet 2 inches
5 feet 3 inches
5 feet 4 inches
5 feet 5 inches
5 feet 6 inches
5 feet 7 inches
5 feet 8 inches
5 feet 9 inches
5 feet 10 inches
5 feet 11 inches
6 feet 0 inches
6 feet 1 inches
6 feet 2 inches
6 feet 3 inches
6 feet 4 inches
6 feet 5 inches
6 feet 6 inches
Expectant Mother's Weight (before pregnancy - if unknown, please estimate)
*
Please enter a number from
50
to
400
.
(Pounds)
Are you aware of any pregnancy related health issues or concerns?
Have you used any of the following during your pregnancy?
*
Cigarettes
Alcohol
Opioids/Heroine
Methamphetamine
Cocaine
Methamphetamine
Crack
Other
Don't worry, we won't judge you in any way - This just gives us an idea any health struggles you might be facing. We will support you no matter what.
If any of the above are selected, please explain
(Amount & Frequency)
Have you ever been diagnosed with any specific health conditions (Physical & Mental)?
*
Have you ever been convicted of a crime?
*
Yes
No
Currently Pending Trial
Prefer not answer
Again - please know that we will not judge you.
Please describe the nature of the charges and/or crime
Would you like us to refer you to a free therapist?
Yes Please
No Thanks
This is a totally free service to help you with depression, confusion, anxiety you are feeling - regardless if it's related to your pregnancy or not.
Expectant Father's Details (if known)
How would you describe yourself to someone who has never met you?
(Example: kind, loving, nervous, hard-worker, intelligent, outgoing, loyal, loving, funny, witty etc)
Expectant Father's Birth Date (if known)
MM slash DD slash YYYY
Expectant Father's Race/Ethnic Background (select all that apply)
*
Asian
Black/African-American
Hispanic/Latino (Non-white)
Hispanic/Latino (white)
Middle Eastern
Native American
Pacific Islander
White/Caucasian
Other Not Listed
Expectant Father's Natural Hair Color
*
Blonde
Brown
Black
Red
Expectant Father's Eye Color
*
Grey
Green
Blue
Brown
Hazel
Black
Expectant Father's Height
*
Please select
Not Sure
4 feet 9 inches
4 feet 10 inches
4 feet 11 inches
5 feet 0 inches
5 feet 1 inches
5 feet 2 inches
5 feet 3 inches
5 feet 4 inches
5 feet 5 inches
5 feet 6 inches
5 feet 7 inches
5 feet 8 inches
5 feet 9 inches
5 feet 10 inches
5 feet 11 inches
6 feet 0 inches
6 feet 1 inches
6 feet 2 inches
6 feet 3 inches
6 feet 4 inches
6 feet 5 inches
6 feet 6 inches
Expectant Father's Weight (estimate if not known)
Please enter a number from
50
to
400
.
(Pounds)
Any Known Health Conditions (Physical & Mental)?
Navigating Adoption
Please let us know what is important to you when choosing a family. Note: Any profiles of families that we present to you will have a full and complete background check and have been legally certified by the state to provide a safe and nurturing environment for your child.
Why are you choosing adoption?
*
Please describe the level of openness you would like to have with the adoptive family
*
Ex: Photos, Letters, Videos, Visits, etc.
What adoptive family types are you willing to consider?
*
(Select as many as you would like.)
Select All
Single Mother
Single Father
Same-Sex Female Couple
Same-Sex Male Couple
Male/Female Couples
No Preference (open to all family types)
Religious Preferences
*
No Preference (open to all faiths)
Atheist/Agnostic
Baptist
Buddhism
Catholic
Christian
Hinduism
Islam
Jewish
Mormon
Protestant
Spiritual
No Religions
Other Not Listed
Is it okay if the family has other children?
*
Yes
No
Feel free to list anything at all you think will be important to you when picking a family: