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Expectant Parent Intake

General Information

How did you hear about Texas Adoption Center?

First Name *

Last Name *

Full Address (Including City & Zip)

Phone Number *

Who else lives with you? List names and relationship to you:

Is your housing situation stable?

Yes

No

If No, Please Explain:

Your Email Address: *

Emergency Contact *

Emergency Contact Phone Number *

Is your emergency contact aware of your adoption plan? *

Yes

No

Age: *

Date of Birth * +

Place of Birth

Social Security Number: *

Driver's License Number:

Religion (if any)

Race *

Caucasian

Hispanic

Native American

Asian

African American

Other

Are you a registered Native American Indian? *

Yes

No

If Yes, List Tribe

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Relationship Status

Check all that apply:

Married

Divorced

Single

In a relationship

Other

Have you ever been legally married? *

Yes

No

Husband's full Name

Date of Marriage +

Place of Marriage

Date of Divorce (if Applicable) +

Father

How many possible fathers are there? * 🛈

Father #1 Full Name *

Father #1 Social Security Number:

Father #1 Driver's License Number:

Father #1 Race

Caucasian

Hispanic

Native American

Asian

African American

Other

Is Father #1 a registered Native American Indian?

Yes

No

If yes, list tribe:

Are you still in contact with him? *

Yes

No

Is he aware of the pregnancy? *

Yes

No

Is he aware of the adoption plan? *

No

Yes

Will he consent to the adoption? *

No

Yes

Please discuss any details about the expectant father situation here: *

Father #2 Full Name

Father #2 Race

Caucasian

Hispanic

Native American

Asian

African American

Other

Is Father #2 a registered Native American Indian?

Yes

No

If yes, list tribe:

Are you still in contact with him?

Yes

No

Is he aware of the pregnancy?

Yes

No

Is he aware of the adoption plan?

Yes

No

Will he consent to the adoption?

Yes

No

Please discuss any details about the expectant father situation here:

Father #3 Full Name

Father #3 Race

Caucasian

Hispanic

Native American

Asian

African American

Other

Is Father #3 a registered Native American Indian?

Yes

No

If yes, list tribe:

Are you still in contact with him?

Yes

No

Is he aware of the pregnancy?

Yes

No

Is he aware of the adoption plan?

Yes

No

Will he consent to the adoption?

No

Yes

Please discuss any details about the expectant father situation here:

Father #4 Full Name

Father #4 Race

Caucasian

Hispanic

Native American

Asian

African American

Other

Is Father #4 a registered Native American Indian?

Yes

No

If yes, list tribe:

Are you still in contact with him?

Yes

No

Is he aware of the pregnancy?

No

Yes

Is he aware of the adoption plan?

Yes

No

Will he consent to the adoption?

Yes

No

Please discuss any details about the expectant father situation here:

Father #5 Full Name

Father #5 Race

Caucasian

Hispanic

Native American

Asian

African American

Other

Is Father #5 a registered Native American Indian?

Yes

No

If yes, list tribe:

Are you still in contact with him?

Yes

No

Is he aware of the pregnancy?

Yes

No

Is he aware of the adoption plan?

Yes

No

Will he consent to the adoption?

Yes

No

Please discuss any details about the expectant father situation here:

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Medical

Estimated Due Date: +

Have you had any prenatal care? *

Yes

No

What State was this pregnancy conceived in?

Has Texas Adoption Center been provided proof of pregnancy?

Yes

No

Name of Doctor:

Address of Doctor:

What hospital will you deliver at?

Is your doctor aware of your adoption plan?

Yes

No

Do you know gender? *

Male	Female
Unsure

When was your last appointment? +

When is your next appointment? +

Do you have transportation to and from your appointments?

Yes

No

Do you have insurance? *

Yes

No

If yes, please list type and number (TAC make a copy of insurance card): Type: Number:

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Support:

Who supports your adoption plan?

Is there anyone in your life who does not support your adoption plan? *

Yes

No

If yes, please explain:

Choosing Adoption

What are your thoughts about parenting the child? *

What are your thoughts about placing the child with a family member? *

What are your thoughts about placing the child for adoption? *

Expectant Parent Signature *

clear

Date: +

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