Find a loving home for your baby.Here at Shape of My Heart Adoption, we’ll walk with you through the journey of placing your child for adoption. If you are ready to begin the adoption process, please complete the intake form below. Your information will be kept confidential. Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Why are you considering adoption for your baby? * What is your due date * MM DD YYYY What is your race? * Asian Black Hispanic White Other Do you have any Native American Heritage? If yes, what you know about your tribal affiliation. * Have you ever been diagnosed with a mental illness, If yes, please describe.? * Have you had any alcohol during your pregnancy? If so, approximately when and how much? * No judgment if you have, it is part of the matching process. Have you taken prescription or other drugs during the pregnancy? If yes, approximately what and when? * Again, no judgment. Do you smoke? * Yes No Are you working? * Yes No Do you have insurance? * Private Insurance Medicaid Will you need help with living expenses (food, rent, utilities, phone, Transportation, etc.) * Write down your expenses here. Would you like an open adoption - pictures & letters, updates or visits? * Yes No I haven't decided Are your friends & family know you are thinking of adoption? Are they supportive of this? * Do you have other children? * Yes No How many? Boys/Girls? How old are they? * What is the health of your other children Do they live with you? * Yes No Sometimes What is the name of this baby's father? * What is the father's race? * Asian Black Hispanic White Other Does the father have any Native American Heritage? If yes, what you know about your tribal affiliation. * Does he know about your adoption plan? * Yes No Unsure Not Applicable Does he support your adoption plan? * Yes No Unsure Not Applicable Will he oppose you adoption plan or want to parent the child? * Yes No Unsure Not Applicable Has he provided you with any type of support (financial or emotional) during the pregnancy? * If so, please describe here. If he has given you financial support, how much and when? What is your relationship with him like now? Are you married to the father? * Yes No If you know, what is his health like? Is there anything else that you think we should know? Thank you!
