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This form is to be
completed by
pregnant women
who are considering
adoption. We will not
respond to other
inquiries.

The Social & Medical History forms are valuable pieces of information for your baby as it grows. Please fill in the form below. You may also download the form in PDF format by clicking here. An adoption counselor will be contacting you the next business day once we have received your completed form. She will help you begin the process and go over your adoption plan.

This is a secure form. American Adoptions keeps all information confidential.

* denotes required field

General Birth Mother Information
* Your Name (First M Last)    
* Birth Date (MM/DD/YYYY)
* Permanent Address
(No P.O. Boxes):
* City / State / Zip: ,    
E-Mail:
How often do you check your emails: Very Often, i.e., at least several times a day.
At Least Once a Day
At Least Once a Week
At Least Once a Month
Seldom, hardly ever checking my emails
* Phone (include area code):
Best time(s) to reach you?:
* Can we leave an identifying message?: Yes   No  
How did you hear about us?
(Other* list below)

* Your Race (check all that apply):
African American Asian Caucasian Hispanic
Native American Other 
* Are you married?: Yes   No      If yes, name of spouse is
* Are you a U.S. citizen?: Yes   No      If no, passport/visa # is
Relationship between Biological Parents
* Do you know the identity of the biological father?: Yes   No  
* Do you know where the biological father is now?: Yes   No  
    If yes, is he also the father of any prior child(ren)?: Yes   No  
* Does he know about the pregnancy?: Yes   No  
* Does he know of your adoption plan?: Yes   No  
* What's his feeling about your adoption plans?:
* Will he sign papers to place the child for adoption?: Yes   No  
* Describe your current relationship with the biological father.
   If you are no longer together, please state when the relationship terminated.:

* Birth Father's Race (check all that apply):
African American Asian Caucasian Hispanic
Native American Other  Unknown
Baby's Information
* When is your due date or child's birth date? (MM/DD/YYYY)
* What is the race of your baby? (check all that apply):
African American Asian Caucasian Hispanic
Native American Other  Unknown
* Have you seen a doctor yet? Yes   No  
* Are you receiving regular pre-natal care during your pregnancy? Yes   No  
Other Information
* Do you have state issued Medicaid? Yes   No  
* Do you have private medical insurance? Yes   No  
* What are your feelings about adoption?

Additional Comments:


Do you want to receive a Birth Mother Packet by mail? Yes   No  

Upon submission you will be contacted back by an Adoption Specialist no later than the next business day!

Our Privacy Policy.

  

Or you may call us at 1-800-ADOPTION



American Adoptions, a private adoption agency founded on the belief that lives of children can be bettered through adoption, provides safe adoption services to children, birth parents and adoptive families by educating, supporting and coordinating necessary services for adoptions throughout the United States. For more information on American Adoptions please call 1-800-ADOPTION (236-7846).
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Related Web Sites:
| OHIO ADOPTION | OPTIONS MAGAZINE | ARKANSAS ADOPTION | ARKANSAS ADOPTION PROGRAMS