Birth Mother's Application to Open Adoption Program

First name

Last name

Date

Month

Day

Year

Decision Making

What are your reasons for considering adoption as a possible plan for your child?

Do you believe you have exhausted all possible means to parent the baby?

What would you have to change for you to be able to raise the child yourself? Is this an option you would like to explore further?

Is there anyone in your family who could help out for a while or perhaps even adopt the baby?

What are your reasons for wanting an open adoption?

What are your specific hopes for your adoption plan?

Do you have any concerns or worries about the way an open adoption might work for you and your child?

What do the significant people in your life (parents, extended family, friends) think about adoption?

Who has been your chief confidante through all this?

What sort of advice have you received?

What’s the very best advice you have received?

Pregnancy

When was the pregnancy first confirmed?

What was your initial reaction?

Was this pregnancy intended or unintended? If unintended, what were the circumstances leading to conception (contraceptive failure, impulsiveness, magical thinking, force, intoxication)?

Have you used any type of birth control? If yes, what type and for how long? Any side effects?

Have you had any previous pregnancies? If yes, when? What was the outcome?

Who is your doctor? How do you feel about your doctor?

Which hospital will you go to for delivery?

How has the pregnancy gone? Any complications? Have you been tense or relaxed?

How has the pregnancy changed your life?

Please describe your diet while pregnant. Any cravings?

Did you use any medications or drugs while pregnant? If yes, please describe.

Personal History

How are you feeling about yourself these days?

How would you describe your personality?

Do you usually find it easy or difficult to trust people?

How are the major relationships in your life working out?

How do you usually relate to children?

How do you handle major disappointments?

How do you express frustration? Anger?

Have you ever been in legal trouble? If yes, please explain.

What is your history relative to alcohol and drugs?

Have you received any counseling or therapy? Please explain.

Has your life been touched by disaster, tragedy, or great sadness?

Has your life been touched by great/good fortune along the way?

What are your goals in life? What will you be doing a year from now? 5 years? 10 years? 20 years?

Family History

What was the atmosphere of the household as you grew up?

What did the family do for fun?

What sort of tensions were there?

Being successful by your family’s standards meant being…

Anyone in the family abusive?Alcoholic ? In legal trouble ? Physically ill? Emotionally ill? If yes, what did it mean for you?

Anybody in the family particularly loving? Outgoing? Intelligent? Attractive Successful? If yes, what did it mean for you?

What has made you the person you are today?

Father of the Baby

How did you meet? When? What attracted you to him?

How would you describe him? What does he look like?

What are his strengths and weaknesses? How would you describe his personality?

Long answer

Describe the relationship when it was/is working well?

Describe the relationship when it was/is not working well?

How do things stand at the moment between the two of you?

What does the future likely hold for your relationship?

What has been his reaction to the pregnancy?

What are his thoughts about adoption? Would he like to be part of the adoption planning?

Are you aware of any significant health issues affecting him or his family?

Are there negative factors about the father that we should be aware of?

What qualities of the father do you hope will be passed on to the baby?