APPLICATION FOR ADOPTION SERVICES: Expecting Parents

Intake for Expecting Parents

Welcome!

We are pleased that you are considering an adoption plan. To ensure we have the information we need to best serve you, please take a few moments to fill out the form below.

If you have any questions, please feel free to contact us at any time: FB / text 587-596-5380 / call 780-421-1177 / email: info@smallmiraclesadoption.com

Thank you!

Contact Information

Your Name

First Name Middle Name Last Name

Due Date (mm-dd-yyyy)

Date

How many weeks pregnant today?

Your Birthdate (m/dd/yyyy)

Date

Birthplace (City/Prov)

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail

Phone Number

- Area Code Phone Number

Marital Status

Single Married Common Law Divorced Separated

Biological Father

First Name Middle Name Last Name

Birthdate (m/dd/yyy)

Date

Birthplace (City/Prov)

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail

Phone Number

- Area Code Phone Number

Description

Birth Mother: Please provide a physical description (eye colour, hair colour and length, height, weight, build, complexion, race etc)

Birth Father: Please provide a physical description (eye colour, hair colour and length, height, weight, build, complexion, race etc)

Referred to Small Miracles Adoption By:

General Information:

Highest Level of Education Achieved:

Future Goals / Aspirations

Current Occupation (or last occupation)

Religion

Catholic Protestant Christian No Denomination Non-practicing Buddhism Hinduism Islamic

Interests, hobbies, talents, sports, achievements

Personality (temperament, feelings about self & others)

Strengths / Improvements Desired

Family History / Relationships (Describe your relationship with your parents, siblings, extended family and any children you may have.)

Please Identify other children born to you (their name, birth date, gender, and who they live with)

Social History: Who primarily raised you?

What is your family's attitude towards pregnancy and adoption?

What is your present relationship with your extended family?

Describe your present relationship with the biological father of the babe and what are his views on this pregnancy and adoption plan?

Medical History:

Describe your present state of health and any past hospitalizations.

Please state any serious illnesses as a child and any serious surgeries.

Describe any physical, mental or emotional medical conditions as well as any treatments .

Describe your present use of alcohol, drugs, tobacco products, and prescription drugs.

Describe use of alcohol, drugs, tobacco products, and prescription drugs DURING pregnancy.

Describe any significant mental health, physical or medical conditions in your extended family.

General Health

Have you or a family member every had the following:

	You	Immediate Family / Parents / Siblings	Paternal Grandparents	Maternal Grandparents	Extended Family / Cousins
Allergies (serious reaction)
Brain Damage
Blood Circulation Problems
Cancer
Cerebral Palsy
Diabetes
Eyes/Ears/Nose/Throat
Epilepsy
Genetic Disorders
Heart Problems
Kidney / Liver Issues
Learning Disorders
Lung Disorders
Mental Retardation
Multiple Sclerosis
Prematurity
Reproductive Disorders
Rheumatism or Juvenile Arthritis
Skin Disorders
Thyroid Disorder

Prenatal Care

When was your pregnancy confirmed and who confirmed the results?

When was your first ultrasound and was there any concerns (if yes, please explain)?

Prenatal History

	Yes	No
Abortion
Bleeding
Caffeine
Complications
Drug Use (intravenous)
Drug Use (marijuana)
Drug Use (meth, crack, cocaine, opiates)
Medical Concerns
Prescription Drug Abuse
Premature Labour
Previous Pregnancy
Previous Pregnancy Loss
Sudden Infant Death
Tobacco (smoking)
X-Rays
Other

Explain the circumstances / reasons why you are choosing to place your child for adoption. Please be specific so that we can best understand what is happening in your life at this time.

I have completed the form and I am confirming my consent to working with Small Miracles Adoption. *

Yes Submit This Form!

2017.07.01