Dear Birth Parent(s):

We would like to help you choose the best possible family in which to place your child and to help you obtain any services which you may need. Please tell us about yourself and what you desire in an adoptive family. Your answers are strictly confidential. If you would like us to phone you, we will call; but if required to leave a message, will simply leave a first name without leaving a number unless you authorize us to do so. We are aware that you may be living in a stressful environment and we do not wish to contribute any additional stress.

If you have any questions or want to discuss your situation,
please contact us at 888-358-BABY (2229).

Are you currently receiving pre-natal care?
Yes No
Do you have medical insurance?
Yes No

What are you looking for in an adoptive family? (see questionairre below)
Religous Preference:

If "other":
 
Race Preference:

If "other":
 

Is age of the adoptive parent(s) a factor?
Yes No Doesn't Matter
 
Would you consider a couple with other children?
Yes No Doesn't Matter
  Are you open to...?
 
Do you prefer a stay-at-home mother?
Yes No Doesn't Matter
  Do you desire parents that live in a specific area of the country?
Yes (enter below) No
  Other traits you desire:
  Your child's age or due date:
  Child's ethnic background. Please select all that apply:
African-American
Asian
Caucasian
Hispanic
Other
If other:

Would you like us to send you information? (packaged confidentially) Yes No

Would you like us to send you family profiles based on your requests? Yes No

If you answered yes to either of these questions, please fill in your information below:
Name:
  Address:
  City:
  State: Zip:
  Phone:
  E-Mail:
  Please contace me via: