Expectant Mother

Date of Birth(if you're not sure, give your best estimate)

What is your current marriage status?
MarriedDivorcedNever married

Do you have Native American Heritage?
YesNo

Expectant Father

Describe your relationship with the father of this baby?

Does he have Native American Heritage?
YesNo

Does he know you are pregnant?
YesNo

Does he agree this is his child?
YesNo

Does he know you are considering adoption?
YesNo

Is he willing to consent to the adoption?
YesNo

Has he helped you financially?
YesNo

if yes, how much?

Due date of baby?

Gender of child:
MaleFemaleUnknown

Have you started prenatal care?(If answer is yes, complete the doctor information below)
YesNo

On a scale of 1 to 10 with 10 being the most committed, how sure are you about placing your child for adoption?
12345678910

Would you like to choose your adoptive family?
YesNo