Pact, An Adoption Alliance - Birth Parent Questionaire

Getting to Know You

If possible, birth mothers and birth fathers should each complete this form separately.

The information you provide will help identify the services you need and want. Please answer the questions as completely as you can. Adoptive parents have been asked to fill out an equivalent form.

Name: Email Address:

Mailing Address: City, State, Zip:

Work Phone: Home Phone:

Best time to call:

How did you
hear about Pact?

What other
adoption resources
have you contacted?

When is your
baby due? What race will
your baby be?

Personal History:

Date of Birth:		Age:
Race:		Nationality:
Occupation:
Previous marriages?	No Yes
How many?		Dates ended:
Citizen?	No Yes
Social Security:		Driver's License:

Do you have a police record? No Yes
If yes, describe circumstances including where and when:

Height: Usual weight:

Eye color: Skin color:

Natural hair color:

Build: small medium large boned Are you: Right handed Left handed

Blood type: RH Factor:

Shoe size: Ring size:

Where were
you born? Where were
you raised?

Were you adopted? How many
siblings do
you have? Sisters Brothers

Feelings About Adoption

What makes you feel you should entrust your child to another family?

Have you considered other options? What other options might be possible?

Who else knows about your adoption plans? What do they think?

Is anyone saying they will help you provide for this baby?
Do you believe they will help you take care of this baby?

Are you	adopted an adoptive parent Have you placed a child before?



Is anyone in your family	adopted an adoptive parent Has anyone placed a child before?
Who?



Do you have friends who are	adopted adoptive parents Have placed a baby for adoption?

What do you think it would feel like to be adopted?

Why do you think someone would want to be an adoptive parent?

What would you want to know about the adoptive parents?

What worries you about taking part in an adoption?

Do you have your heart set on finding a particular kind of family for your baby? Please describe:

Describe any family you cannot accept:

How do you think race matters in an adoption?

What do you think might make it hard for another family to adopt your baby?

Have you thought about whether you want to meet the adoptive parents?

What kind of ongoing contact do you want with the baby? How often?

Family Situation

Do you have children? No Yes

Who are you afraid to tell about this adoption? What do you think would happen if you told them?

Who thinks this adoption is a bad thing for you to do?

Have you ever been unable to go to
work because of a hangover? Yes No

Have you ever been in an accident
because of drinking or drugs? Yes No

Does anyone in your family
have a drinking or drug problem? Yes No If yes, who?

Do you smoke? Yes No

How often do you drink wine, beer, and/or alchohol? twice a day daily weekly monthly never

How often do you use drugs? twice a day daily weekly monthly never

Are you willing to take an HIV test? Yes No

Are you willing to take drug tests? Yes No

How actively do you participate in your current religion? Describe:

Last grade completed: Date completed:
School attended:

For Birth Mothers Only

When did you start prenatal care?

Do you have insurance? Yes No

Name, policy number, group number:

Hospital (name, address, phone):

Ob/Gyn (name, address, phone):

How long have you seen this doctor?

How are you covering the expenses of this pregnancy?

If the birth father is not available to fill out this form, is he willing to consent to this adoption?

Is there anything else you think we should know?

Name:		Email Address:
Mailing Address:		City, State, Zip:
Work Phone:		Home Phone:
Best time to call:
How did you hear about Pact?
What other adoption resources have you contacted?
When is your baby due?		What race will your baby be?

Do you have a police record?	No Yes
If yes, describe circumstances including where and when:

Height:		Usual weight:
Eye color:		Skin color:
Natural hair color:
Build:	small medium large boned	Are you:	Right handed Left handed
Blood type:		RH Factor:
Shoe size:		Ring size:
Where were you born?		Where were you raised?
Were you adopted?		How many siblings do you have?	Sisters Brothers

Have you ever been unable to go to work because of a hangover?	Yes No
Have you ever been in an accident because of drinking or drugs?	Yes No
Does anyone in your family have a drinking or drug problem?	Yes No If yes, who?
Do you smoke?	Yes No
How often do you drink wine, beer, and/or alchohol?	twice a day daily weekly monthly never
How often do you use drugs?	twice a day daily weekly monthly never
Are you willing to take an HIV test?	Yes No
Are you willing to take drug tests?	Yes No