Forms

Birth Mother Intake

Your Name

What is Your Due Date?

Cell Phone (with area code)

Other Phone (with area code)

Email Address

Address

Address line 2

City

State

Zip

Birth Mother Age

Describe Your General Health:

Have you ever been diagnosed with mental illness, if so describe.

Have you consumed alcohol during this pregnancy, if so describe.

Have you done any prescription or other drugs during this pregnancy, if so describe.

Do you smoke?

yesno

Are you currently employed?

yesno

Do you currently have medical coverage?

yesno

Have you received prenatal care during this pregnancy?

yesno

Will you need help with living expenses during this pregnancy, if yes explain needs.

Are you open to meeting the family who adopts your baby?

yesno

Would you like pictures or updates after the baby is born?

yesno

Would you like visits after the baby is born?

YesNo

Why are you considering adoption, explain.

Does your family know about the adoption?.

YesNo

Does your family agree?

YesNo

Other Children?

YesNo

How Many?

Boys

Girls

Ages

General health of your children, describe

Do they live with you?

yesnosometimes

Do you know who the father of the baby is?

yesno

Does he know about the adoption?

yesno

Does he support the adoption?

yesno

What is your current relationship with the birth father, describe.

If he does not, will he oppose and try to parent?

yesno

Are you legally married to the birth father?

yesno

Are you legally married to someone other than the birth father?

yesno

Describe fathers general health

Has the birth father ever been diagnosed with mental illness, if so describe.

Any other information

Medical Release

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

Patient’s Full Name (printed):

Address:

City, State & Zip:

Date of Birth:

I authorize:

Doctor’s Name

Doctor’s Address

City, State & Zip

Doctor’s Phone

Doctor’s Fax:

To use and disclose the protected health information described below to A Loving Alternative Adoption and their clients and other individuals involved in my plans for an adoption.

Effective Period:

This authorization shall be in force and effect until ten days after the completion of this pregnancy at which time this authorization expires.

Extent of Authorization:

I authorize the release of my complete health records (including records related to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). This medical information may be used by the person I authorize to receive this information as background information pursuant to my plans for an adoption.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I further understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of patient

Date

let Us Help You

Please complete and submit these forms. If you have any questions please call. Once we have received the information we will contact you to explain next steps.

Birth Mother Intake

Expectant Mother Living Expense Form

Monthly Income:

Monthly Expenses:

Medical Release

HIPAA Privacy Authorization Form

I authorize:

Effective Period:

Extent of Authorization: