Adoption and Surrogacy Questionnaire

Questionnaire

Making the decision to adopt is an important life-changing event and we are here to partner with you on this journey. Please fill out this safe and secure form below to begin the process. Once submitted, please contact Joanna Ivey to create your personalized adoption profile.

Adoptive Parent 1

First Name*

Maiden Name

Gender*

Middle Name

Address*

Last Name*

City*

State*

Zip*

Phone*

Email*

SSN*

Date of Birth*

Place of Birth*

Height*

Weight*

Eyes*

Hair*

Ancestry* - Please specify any American Indian heritage including name of Tribe and if you are registered.

Religion* - Specific Denomination

Adoptive Parent 2

First Name

Maiden Name

Gender

Middle Name

Address

Last Name

City

State

Zip

Phone

SSN

Date of Birth

Place of Birth

Height

Weight

Eyes

Hair

Ancestry - Please specify any American Indian heritage including name of Tribe and if you are registered.

Religion - Specific Denomination

Additional Information

Date of Marriage

Other Children - Indicate sex, date of birth and if biological or adopted

Pets

Parent 1 Occupation*

Parent 2 Occupation

Approximate Combined Annual Income*

What are your work plans once child is placed with you?*

Areas of Interest*

Reason for Adoption*

Describe your General Health*

Would you accept a situation in where the birth mother has or is using drugs or alcohol during the pregnancy?
(Check all that you would accept)

Alcohol

Tobacco

Marijuana

Cocaine

Meth

Heroin

Additional Comments

Would you accept a situation where the birth mother has a history of mental health disorders?
(Check all that you would accept)

Bipolar

Depression

Schizophrenia

ADD/ADHD

Additional Comments

Openness in Adoption*
(Check all that you would accept)

Totally Closed Adoption
No contact

Semi-Open
Exchange of pictures and letters

Completely Open Situation
Interaction both before and after birth, knowledge of identifying information

Additional Comments

Race of Child*
(Check all that you would accept)

Caucasian

Hispanic

African American

Native American

Asian

Biracial: Please Specify Races

Additional Comments

Insurance Information

Insurance Coverage*

Does Policy Cover Birthmother Charges?*

Yes

Does Policy Cover Baby’s Charges?*

Yes

Budget*: Including legal fees and expenses, medical fees and living expenses

* Funds need to be ready within 48 hours of matching.

Are you interested in talking with an adoption finance coach?*

Yes

Additional Comments

Do you have a home study that is current within one year?*

Yes

Date of Home Study

Agency/Social Worker

Address

City

State

Zip

Phone

Date of FBI Clearances

Date of Child Abuse Clearances

Date of Local State Clearances

How did you hear about MPOWB?*

OPTIONAL PHOTO USE* (Details below)

Yes

Please choose yes or no to permit us to use photos provided by you on our website and on social media sites. Your choice will have no impact on the service we provide and is completely optional. If you choose to allow us to use your photo, you may request removal of the photo in the future and we will make every effort to remove it from this site in a reasonable time frame. Notwithstanding, certain social media sites may have delayed or differing removal policies and we are not responsible for those sites. For more information, please see our full terms and conditions and privacy policy.

Martin Pringle

Adoption & Surrogacy : Kids can be messy.

Questionnaire