Mother's Name Age

Birth DateDue Date

Address

City State Zip

Home Phone Work Phone

Marital Status Other Children

Do they live with you? Medical Insurance to cover pregnancy?

Health History

Nationality (race, eithnic background, including any American (Indian) ancestry)

Education Level

Employment

Physical Appearance

Mental Health (include any current or previous dependency on drugs and/or alcohol or treatment for any of the aforementioned.

Do you smoke? If yes, number of packs?

Any information you feel we should know about your general health during the pregnancy?

Describe your general personality (include interests, talents, school, etc.)

Reason for adoption

IMPORTANT: Please describe the family you wish to adopt your baby. Keep in mind that we have many clients of varying backgrounds, races, religions, etc. Let us know if it is OK that there is another child in the home (or not). Some of our clients are single people, is that OK? Be as specific as you wish and we can discuss when we talk again.

Anticipated Expenses (Estimated)

Medical Bills

Name of Medical Provider (if applicable)

Living Expenses

Other Professional/Miscellaneous Expences