Birth Mothers Help

We help match birthmothers with prospective adoptive parents.
Learn more here.

Request an Information Packet
Birthmother Application Form
Or call us toll free at
1-800-450-7191

Birthmother Application

There is a choice...

Thank you for starting the application process. We realize this decision is one of the most difficult you have ever made, and we are more than happy to be there to guide you through this challenging time. This is a secure form. All information is submitted confidentially.

Please supply a phone number where we can reach you; we would very much like to speak with you. We will call you and answer any questions you have. If someone else were to answer the phone, we will not disclose that we are an adoption agency to anyone other than you. We keep your information strictly confidential.

Once we receive the application, we will mail you a medical release and HIPAA agreement for you to sign. We will also need proof of pregnancy (an ultrasound or something from a doctor stating that you are pregnant). Feel free to fax proof of preggnancy if you can to 207-655-1249.

This form is for birthmothers looking to place a child for adoption. If you are looking to adopt a child, please visit www.storksearch.org.

Birthmother Personal Information

Your Name (first and last)

Address Line 1

Address Line 2

City

State

Zip/Postal Code

Country

E-mail Address

Phone Number

Social Security Number

Driver's License Number

D.L. State

US Citizen?Yes No

If No, What Country?

If No, Do You Have A Green Card?Yes No

Your Race

Ethnic Background

Native American Indian

It is important for us to know if you are a member of any Native American Indian Tribe. Please answer the following question to the best of your knowledge: Are you a member of any Native American Indian tribe? Yes No

Your Age

Your Height

Your Eye Color

Your Complexion

Your Bone Structure

Your Hair Color

Your Hair Type

Left or Right Handed?Left-handed Right-handed

Your Marital Status

Your Marital History

Your Baby

Due Date (mm/dd/yy)

This Baby Will Be:

Employment and Education

Your Employment HistoryFrom: To:

Company

Telephone

Your Supervisor

Employer's Address

School Attending, or Attended

Family

Child 1Name
Lives with Age

Child 2Name
Lives with Age

Child 3Name
Lives with Age

Your Mother's Full Name

Your Father's Full Name

Siblings

Brief Description of Life Growing Up

Adoption Choices

Referred By

I came to the decision to place for adoption because:

I have considered these other plans:

My parents have advised me, or want me to:

Does the birthfather know about this pregnancy?Yes No

The birthfather wants me to:

My true feelings about adoption are:

I would like to place with a: Age Range

I would like an:

Please give a reason for your answer:

Do you need financial assistance?Yes No

Please list only what you absolutely need for assistance, if any.

After the child is born, I plan to:

The person I most see helping me throught this is, and why?:

Birthfather

Birthfather's Name

Address

City

State

Birthfather's Telephone

Birthfather's Age Birth Date (mm/dd/yy)

Personality Traits (Good or Bad)

Birthfather's Occupation

Birthfather's Education

Birthfather's Height

Birthfather's Eye Color

Birthfather's Complexion

Birthfather's Bone Structure

Birthfather's Hair Color

Birthfather's Hair Type

Left or Right Handed?Left-handed Right-handed

Birthfather's Marital Status

Birthfather's Race

Birthfather's Ethnic Background

Criminal Background

Have you been arrested in the last 5 years?Yes No

If yes, please indicate type of crime(s)Misdemeanor Felony Drug-related Other

If yes, please state the circumstances.

Health

Condition	Yes	No	You	Relative	Type/Treatment
Alcoholism

Allergies	Yes	No	You	Relative	Type/Treatment
Hayfever
Food
Local Anesthetic
Penicillin
Other Antibiotics
Sulfa Drugs
Codeine
Aspirin
Mercury
Other Allergies

Condition	Yes	No	You	Relative	Type/Treatment
Anemia
Arthritis
Asthma
Frequent Colds
Chronic Bronchitis
Blindness
Cataracts
Cross-eyed
Near Sighted
Far Sighted
Other Eye Ailments

Blood Conditions	Yes	No	You	Relative	Type/Treatment
Diabetes
Hemophilia
RH Negative
High Blood Pressure
Low Blood Pressure

Condition	Yes	No	You	Relative	Type/Treatment
Bi-Polar Disorder
Down Syndrome
Cerebral Palsy
Chromosome Disorder
Cleft Palate
Club Foot
Crippling Disorder
Cystic Fibrosis
Deafness

Diseases	Yes	No	You	Relative	Type/Treatment
AIDS
Alzheimer's
Cancer
Hodgkin's
Huntington's
Kidney
Liver
Venereal

Drug Use or Addiction	Yes	No	You	Relative	Type/Treatment
Cigarettes
Alcohol
Marijuana
Cocaine
Methamphetimines
Heroin
Ecstasy
Methadone
LSD
Caffeine
Other Stimulants
Depressants
Diet Pills
Tranquilizers
Anti-convulsants
Other Drugs

Condition	Yes	No	You	Relative	Type/Treatment
Eczema/Skin Conditions
Epilepsy
Glaucoma
Genetic Disorder
Hair Lip
Heart Attack
Heart Disease
Hormone Disorder
Hysterectomy
Hydrocephalus
Learning Disability
ADD/ADHD
Malformations
Manic Depression
Retardation
Clinical Depression
Muscular Dystrophy
Schizophrenia
Paralysis
Seizures
Sickle Cell
Speech Problems
Spinal Bifida
Stroke
Thyroid Disorder
Tuberculosis
Tumors
Dental Problems
Scoliosis
Bone Disorders
Accidents
Current Prescription Drugs
Other

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