Congratulations! You have made  the best decision

 for you and for your baby. Michelle is waiting to help

 you find the right home for your baby!

Michelle will need information from you and your

agreement for her to be your legal representative. 

You may copy and complete the form now or in her office.

If you need help call 1-805-650-6160!

BIRTHMOTHER INFORMATION

Date ____________Due date _____________ Child's Sex ______________

Full name ______________________________________________

Other names used ________________________________________

Home address ____________________________________________

______________________________________________________

Phone numbers_________________________________________

Family aware of Adoption plan? ____ Do they agree/support? _____

Social Security No. ._____________ Drivers Lic. _______________

American Indian? _____ Registered? _____

Live-with the baby's father during past year? ________ Dates _______

Date of birth _____________________ Place of birth ___________

Age _____ Race ______________ Religion _________________

Hair ______ Eyes _____ Complexion ______ Height ______ Weight _____

Marital status: (  ) Single (  ) Divorced (  ) Separated (  ) Married

Are you married but your husband is not the father of the child? _______

Your other children : Name, age, father's name, live with you?

1. _____________________________________________________

2. _____________________________________________________

Employer _________________________________________

Pregnancy history

Your Health: (1-10 scale) _______
Any conditions/illnesses? __________________

Any problems with this pregnancy? __________________________

List medications taken during this pregnancy ___________________

Smoke? ___ During this pregnancy? ____ How much? ____________

Drink alcohol? ____ During this pregnancy? _____
How much/ how often? _________________

Drug use? ____ During this pregnancy? _____

What?/How much?/ How often? ____________________________

Medical information

OB Doctor's name, address, phone _____________________________

____________________________________________________

Hospital name, address, phone ____________________________

____________________________________________________
Pre-registered? _________________________________

General information

Any criminal convictions? You? _______________/the father? _______

Drug arrests/convictions? You? _______________/the father? _______

Any accusations of child abuse/neglect? You? __________ the father? ____

Has CPS ever taken a child from you? ________

Previous adoption placments: Description with date(s)

_________________________________________________________

Why have you chosen adoption for this child?

_________________________________________________________

Child's Father's Full Name (if known)_____________________

Address ____________________________________________

Phones ___________________________________________

His Age __________ Race _____________ Hair ______ Eyes _____ 

Complexion ______ Height _____ Weight __________

Date of birth _____________________
Place of birth ____________________________________

Social Security No. ________________
Drivers Lic. _____________________

American Indian? _____ Registered? _____

His Other children : Name, age, mother's name, live with him?

1._____________________________________________________

2.____________________________________________________

Ishe current on all child support? _________

Did you tell him of pregnancy? ______ Adoption plan? _______________

Does he Agree to adoption plan _____

MEDICAL INFORMATION: Please list any serious illnesses or condition or yourself or any family member. ___________________________________________________

_____________________________________________________________________

____________________________________________________________________

Indicate medications/drugs taken during this pregnancy:

YES /NO 

1. Aspirin

2. Antibiotics

3. Antihistamines Types __________

4. Hormones Types __________

5. Cortisone (ACTH, etc.)

6. Diet pills Types __________

7. Sleeping pills Types __________

8. Nerve pills/ tranquilizers

9. Medicine for cancer Type _________

10. Heart/blood pressure pills Type _________

11. Thalidomides

12. Medicine for nausea Type _________

13. Medicine for convulsions

14. Nose drops

15. Alcohol

16. Amphetamines Type _________

17. Barbiturates

18. Cocaine

19. Heroin

20. LSD

21. Marijuana

22. Cigarettes

23. Folic acid

24. Other vitamins and dietary supplements

______Have you had any X-ray exposure since your
last menstrual period?

Describe: ___________________________________________________

____________________________________________________________

______ Have you been exposed to any chemicals

______ Have you ever had genital herpes?

_______Have you had diabetes/gestational diabetes?

_______ Have you had syphilis or other venereal disease?

BIRTH PARENT ACKNOWLEDGMENT

I, the undersigned, represent that the information contained
in the Adoption Information Application and Medical Information form is true and accurate. I acknowledge that the adoptive parents and other parties will  rely on this information in making a determination to proceed  with the anticipated adoption. I further understand that any false statement herein is perjury  and in violation of penal laws of my state and may subject me to criminal and/or civil penalties under the law.

_______________________________     _______________

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