Expectant Parent Care Plan

Expectant Parent Name: *

CURRENT FINANCIAL RESOURCES

What is your current monthly income (include any benefits)?

Will your financial situation change between now and delivery?

Yes

No

Does anyone support you financially? *

Yes

No

If yes, who and in what ways?

Are you behind on any bills? (i.e., housing, electric, water) *

Yes

No

If yes, please explain:

Save & Return

Use an account to return to saved work.

MONTHLY EXPENSES

ASSISTANCE REQUESTED: DETAILS

Assistance Requested: Rent * 🛈

	Details
Rent Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Reason for need assistance with rent: *

I am homeless and need TAC to provide financial support for safety and stability during my pregnancy and postpartum recovery.

I am unemployed and need TAC to provide financial support for safety and stability during my pregnancy and postpartum recovery.

I have decreased income temporarily and need TAC to provide financial support for safety and stability during my pregnancy and postpartum recovery.

I am not requesting assistance with rent.

Other Other

Save & Return

Use an account to return to saved work.

Assistance Requested: Electric * 🛈

	Details
Electric Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Assistance Requested: Gas * 🛈

	Details
Gas Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Assistance Requested: Water * 🛈

	Details
Water Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Assistance Requested: Trash * 🛈

	Details
Trash Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Reason or explanation for assistance (Utilities): *

I am unemployed and need TAC to provide financial support to keep my utilities active during my pregnancy and postpartum recovery, in order to keep my home’s climate safe during extreme weather, allow for refrigeration of medication/food, and meet other basic needs.

I have decreased income temporarily and need TAC to keep my utilities active during my pregnancy and postpartum recovery, in order to keep my home’s climate safe during extreme weather, allow for refrigeration of medication/food, and meet other basic needs.

I am not requesting assistance with utility bills.

Other Other

Assistance Requested: Cell Phone * 🛈

	Details
Cell Phone Amount:	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Reason or explanation for assistance (cell phone): *

I am unemployed and need TAC to provide financial support to ensure I have a way to make contact in an emergency, such as going into labor, or other urgent needs during my pregnancy or postpartum recovery period.

I have decreased income temporarily and need TAC to ensure I have a way to make contact in an emergency, such as going into labor, or other urgent needs during my pregnancy or postpartum recovery period.

I am not requesting assistance with my cell phone bill.

Other Other

Save & Return

Use an account to return to saved work.

Assistance Requested: Medical bills *

	Details
Medical (prenatal & labor and delivery only)	Details

Any balance past due? *

Yes

No

Past due amount? Please provide details.

Reason or explanation for assistance (medical bills): *

I am uninsured and need TAC to provide financial support for pregnancy related expenses to ensure I have the appropriate medical care for myself and the baby, during the pregnancy and postpartum recovery period.

I have private insurance and need TAC to provide financial support for pregnancy related expenses that are not covered to ensure I have the appropriate medical care for myself and the baby, during the pregnancy and postpartum recovery period.

I am not requesting assistance with my medical bills because I have pregnancy Medicaid coverage.

Other Other

Childcare *

	Child Care (only while hospitalized for delivery)			Do you have children in your care?
	Yes	No		Yes	No
Assistance Requested	Yes	No		Yes	No

Save & Return

Use an account to return to saved work.

Assistance Requested: Groceries / Hygiene / Transportation *

$20 daily (no children in your care)

$25 daily (children in your care)

Reason or explanation for assistance: *

I am unemployed and need TAC to provide financial support to keep myself and the baby nourished and healthy during pregnancy and postpartum recovery.

I have decreased income temporarily and need TAC to keep myself and the baby nourished and healthy during pregnancy and postpartum recovery.

Other Other

Save & Return

Use an account to return to saved work.

Assistance Requested: Clothing *

	Amount Requested
Maternity Clothing (Maximum $300):	Amount Requested

Are maternity clothes available?

Yes

No

Reason or explanation for assistance: *

I am unemployed and need TAC to provide financial support for adequate clothing for growing pregnancy belly.

I have decreased income temporarily and need TAC to provide financial support for adequate clothing for growing pregnancy belly.

I am not requesting assistance with clothing.

Other Other

Save & Return

Use an account to return to saved work.

- We can only begin assisting financially when you are at least 20 weeks along in your pregnancy and matched with a family.

- Texas Adoption Center is bound by the laws of Texas about what we can assist you with financially and for how long. If you have any questions, ask your Adoption Specialist.

- The goal of financially assisting you is to keep you safe and stable during your pregnancy and while you recover from delivery.

- If you are not working your adoption plan, staying in regular touch with your Adoption Specialist, attending doctor’s appointments, we won’t be able to assist you financially.

- If we’ve tried to reach you for 2 days and you have not responded, we will assume you are no longer working with us and we will no longer fund your PEX card.

- In order to pay your rent, your Adoption Specialist must be able to see where you live and speak with your landlord.

- Rent is paid directly to your landlord between the 2^nd and 3^rd of every month.

- Utilities and cell phone are paid directly to the company unless they’re included in your rent.

- Funding for groceries, hygiene products, and transportation are given to you on a PEX card. You will receive an amount distributed daily by an automatic transfer to your PEX card. You can choose to use your funding every day or save up a few days for a bigger shopping.

- We are only able to assist with a maximum of $300 towards amount for maternity clothing. We break the amount up over the course of your pregnancy. We add this amount to your PEX card when you’re ready to use it.

- Emergency funding is NOT available. If you anticipate a financial emergency, please let your Adoption Specialist know as soon as possible so we can avoid a crisis.

- Funding for your living expenses is paid by the adoptive family and passed through the agency to help you stay safe and stable during your pregnancy.

- In Texas, it is illegal for adoptive parents to give you money unless they’re paying your living expenses through a licensed agency, like ours.

- Adoptive parents are aware they are not allowed to give you money directly. They are required to refer you back to your Adoption Specialist and let the Agency know if you ask them directly for money.

- If you choose to parent after receiving expenses, you will not be required to pay back the funds you received.

PHYSICAL HEALTH

Are you having any pregnancy-related dental emergencies? *

Yes

No

EMOTIONAL HEALTH

Your Adoption Specialist will provide you with options counseling, grief and loss counseling, adoption education, childbirth preparation and ongoing emotional support. Would you like the Agency to set you up with additional counseling outside the agency? *

Yes

No

Describe Texas Adoption Center’s plan to assist with your emotional and physical health and wellness during pregnancy and after delivery. *

Texas Adoption Center is going to provide me with ongoing emotional support during my pregnancy and postpartum recovery period. I will receive education about the adoption process, as well as grief and loss support from my Adoption Specialist. If I need additional support, I will inform my Adoption Specialist.

Other (Describe below)

What assistance programs are you part of right now (i.e.-SNAP, WIC, Medicaid, CHIP etc.)?

	Details
Monthly amount received from WIC:	Details
Monthly amount received from SNAP/Food stamps:	Details
Estimated weekly amount spent beyond state benefits:	Details

Would you like the Agency to assist you to find out if you’re eligible for additional community resources?

Yes	No
If yes, what services are you interested in: If yes, what services are you interested in:

Save & Return

Use an account to return to saved work.

ADOPTION SPECIALIST ROLE

-Your Adoption Specialist will help you get to and from your pregnancy-related appointments. There may be times when she is not available to take you, but she’ll try to take you as often as she can.

-Your Adoption Specialist is here to provide you emotional support.

-Your Adoption Specialist is here to help you get to know your adoptive family, if that’s part of your adoption plan.

-In order to provide you the best service possible, your Adoption Specialist needs time to recharge. She is available Monday through Friday during regular business hours, aside from emergencies.

-She may schedule a meeting outside of her normal hours, but that does not mean she’s always available.

Please only text or call your Adoption Specialist outside of her normal hours or on the weekend if you are in labor

Your signature *

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