Birth Plan

First name

Last name

Birthday

Month

Day

Year

Today's Date

Month

Day

Year

Due Date

Month

Day

Year

I am planning to do an adoption

I have not yet decided

Adoption Agency

Phone

Adoption Advocate

Phone

Adoptive Parents’ First Names:

Have their last names been changed? If so, list here.

List potential name options if applicable

The Baby’s Father:

Is involved

Will come to see the baby

Will visit me

Is not involved

Expected and approved visitors:

The Adoptive Parents:

Will visit me in labor

Will visit me postpartum

Will attend the birth

Will only visit the baby in the hospital when I am notified

Will visit the baby in the hospital with these limitations

May provide care for the baby

Special Requests

I have reviewed this form and feel it reflects my wishes at this time. I reserve the right to make changes at any time through notification of my social worker, nurse, midwife or physician.

Birth Mother Signature

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Birth Father Signature

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