Birth Parent Information Request | A Child's Waiting Adoption Program

05/14/08

· Are You Pregnant? > Request Information

Thank you for your interest in our programs.
We encourage you to contact us by phone so we may personally discuss your needs.

1-866-YES-ADOPT
An adoption professional is available 24/7 for Birth Parent assistance.

Alternatively, please complete the form below, and we will contact you shortly.

Name(s):
Address:
City:		State:
ZIP:		County:
Home Phone:		Can We Leave a Message?	Yes No
Mobile Phone:		Can We Leave a Message?	Yes No
Alternate Phone:		Can We Leave a Message?	Yes No
Should we block Caller ID when we call?			Yes No
Best time to call you?
E-Mail:
Re-Enter E-Mail:
Due Date or Child's Date of Birth
Your Date of Birth
Your Race / Heritage
Baby's Race / Heritage
Marital Status
Single	Married	Separated	Divorced	Other
Is your child already born?	Yes No
Describe your feelings and your reasons for making a possible adoption plan.

Are you open to counseling by an adoption specialist?
Yes No
Explain the type of family you would want for your child.

Do you wish to select the family yourself? (Some parents ask for the agency to select an adoptive parent.)
Yes No
After the child is placed, do you hope for any degree of "openness?"
Yes No
If yes, please check all that apply:
Look at photos of possible families.
Read "Dear Birthparent" letters.
Phone interview before placement.
In person meeting before placement (if possible).
Letters and pictures to be sent and recieved through agency.
Possible visits after placement.
Other:
How did you hear about us?