Date of Birth
What is your current marriage status?
Do you have Native American Heritage?
Describe your relationship with the father of this baby?
Does he have Native American Heritage?
Does he know you are pregnant?
Does he agree this is his child?
Does he know you are considering adoption?
Is he willing to consent to the adoption?
Has he helped you financially?
if yes, how much?
Due date of baby?
Gender of child:
Have you started prenatal care?(If answer is yes, complete the doctor information below)
On a scale of 1 to 10 with 10 being the most committed, how sure are you about placing your child for adoption?
Would you like to choose your adoptive family?