Information Form/Request for Service

Information Form/Request for Service - Adoption Choices of Nevada

111 Washington St.,
Reno, NV 89503
Las Vegas CALL 702-474-4673
Reno CALL 775-825-4673
TEXT 702-608-1241

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I Just Gave Birth
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Contact Us

Information Form/Request for Service

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Information Form/Request for Service

Information Form/Request for Service

Information Form/Request for Services

Adoption Choices of Nevada

A Note from Adoption Choices of Nevada

Thank you for taking the time to complete this form. This information will assist us in better meeting your needs and helping you with the adoption process.

IDENTIFYING INFORMATION OF BIRTH MOTHER:

Name:(Required)

First Last Initial

Street Address:(Required)

City:(Required)

State:(Required)

Zip:(Required)

Phone Number:(Required)

Email:(Required)

Age:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Place of Birth:(Required)

Religion:

Employer:

Work Hours:

Work Phone Number:

Emergency Contact Name:(Required)

First Last

Emergency Contact Phone Number:(Required)

How do you know your emergency contact?(Required)

Race of Birth Mother:(Required)

Are you Native American Indian?(Required)

Yes

Are you or any member of your family registered with a tribe?(Required)

Yes

If yes, which tribe:(Required)

Ethnicity: (check all that apply)(Required)

French

Irish

Greek

Italian

English

German

Dutch

Scottish

Scandinavian

Hispanic

Other

Please Indicate "Other":(Required)

Height:(Required)

Non-Pregnant Weight:(Required)

Eye Color:(Required)

Hair Color:(Required)

Hair Texture:(Required)

Skin Complexion:(Required)

Body Build:(Required)

Medical

Due Date:(Required)

MM slash DD slash YYYY

Has the due date been confirmed?(Required)

Yes

If no, when was your first day of your last menstrual period?(Required)

MM slash DD slash YYYY

Have you had an ultrasound?(Required)

Yes

If yes, date:(Required)

MM slash DD slash YYYY

Where did you have the ultrasound?(Required)

Sex of Baby:(Required)

Male

Female

Unknown

Is this going to be a multiple birth?(Required)

Yes

Unknown

If yes:(Required)

Twins

Triplets

Other

Have you been told there are any medical issues with this pregnancy?(Required)

Yes

If yes, what issues?(Required)

Do you have any medical coverage?(Required)

Yes

Will Be

Have Applied

Don't Qualify

What is your medical coverage?(Required)

Do you have transportation to and from your doctor?(Required)

Yes

Who is Your Doctor?(Required)

Doctor Address:

Doctor Phone Number:

When was your last appointment?(Required)

When is your next appointment?(Required)

Have you been to any other doctors/clinics/hospitals during this pregnancy?(Required)

Yes

If yes, name and address of doctor/clinic/hospital:(Required)

Has your doctor told you that you will have a cesarean section delivery?(Required)

Yes

What hospital are you using?(Required)

Is the doctor aware of the adoption?(Required)

Yes

Do you take any illegal drugs?(Required)

Yes

If yes, what?(Required)

If yes, how often?(Required)

Do you drink alcohol?(Required)

Yes

If yes, how much?(Required)

If yes, how often?(Required)

Do you smoke cigarettes?(Required)

Yes

If yes, what kind?(Required)

If yes, how many per day?(Required)

Do you have any medical problems?(Required)

Have you had an HIV test?(Required)

Yes

If yes, when and where?(Required)

Have you ever received any psychiatric counseling and/or treatment?(Required)

Yes

If yes, how long and at what age?(Required)

Were you:(Required)

Inpatient

Outpatient

What was the diagnosis?(Required)

What, if any, medication was prescribed?(Required)

Is there any mental illness in your family?(Required)

Yes

If yes, who?(Required)

Are you a twin?(Required)

Yes

If yes, are you:(Required)

Identical

Fraternal

Is your twin male or female?(Required)

Male

Female

Do you have other children?(Required)

Yes

If yes, who do they live with?(Required)

If yes, please list their age and gender:(Required)

If yes, what is their health history?(Required)

Have you ever considered adoption during a previous pregnancy?(Required)

Yes

What was your previous labor like?(Required)

Total Pregnancies:(Required)

Total Miscarriages:(Required)

Total Abortions:(Required)

Marital Status

What is your marital status?(Required)

Single

Married

Separated/Divorced

If married, when and where:(Required)

If separated or divorced, when and where:(Required)

Husband's full name:(Required)

Husband's address (if different than yours):(Required)

Husband's phone number:(Required)

Birth Father

Is the Birth Father aware of your pregnancy?(Required)

Yes

Is the Birth Father aware of the adoption plan?(Required)

Yes

Will the Birth Father Consent to the Adoption Plan?(Required)

Yes

Not sure

Do you currently reside with the Birth Father?(Required)

Yes

Birth Father's name:(Required)

First Last

Birth Father's Date of Birth (if known):(Required)

Birth Father's Phone Number

Birth Father's Address:(Required)

Street Address City State ZIP Code

Birth Father's Race:(Required)

Is the Birth Father Native American?(Required)

Yes

Is he or a member of his family registered with a tribe?(Required)

Yes

If yes, which tribe?(Required)

Ethnicity of Birth Father:(Required)

French

Irish

Greek

Italian

English

German

Dutch

Scottish

Scandinavian

Hispanic

Unknown

If other, please describe:(Required)

Birth Father's Height:

Birth Father's Weight:

Birth Father's Eye Color:

Birth Father's Hair Color:(Required)

Birth Father Hair Texture:(Required)

Birth Father Skin Complexion:(Required)

Birth Father's Body Build:(Required)

Birth Father's Employer:(Required)

Adoption Plan

What are your reasons for considering adoption for your baby?(Required)

Are you sure about this decision?(Required)

Yes

If no, why?(Required)

Are you being pressured to make this decision?(Required)

Yes

If yes how are you being pressured and who is pressuring you?(Required)

What would make you reconsider adoption?(Required)

Are your parents aware of this pregnancy?(Required)

Yes

Are your parents supportive of adoption?(Required)

Yes

Are your friends aware of your adoption plan?(Required)

Yes

Who is your support system during this pregnancy and for the adoption?(Required)

What is your current living situation?

Have you ever been arrested?(Required)

Yes

If yes, what for?(Required)

Are you currently facing any legal problems?(Required)

Are you working with any other Adoption Agencies? If yes, which one(s)?(Required)

Have you quit working with any other Adoption Agencies? If yes, which one(s)?(Required)

Other

How did you hear about Adoption Choices of Nevada?(Required)

Internet (Google Search)

Internet (Advertisement)

Friend

A professional (doctor, nurse, social worker, etc.)

A hospital or clinic

What search terms did you use to find us?(Required)

Which professional or hospital/clinic?(Required)