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Application-Birthmother

  • Completing this application should take between 5-10 minutes. Please make sure to answer as many questions as you can. Make sure to hit the "Submit Application Now" button at the end. Thank You.
  • TELL US ABOUT YOURSELF

  • PHYSICAL INFORMATION

  • TELL US ABOUT THE BIRTHFATHER

  • Please answer as many questions as you can.
  • PREGNANCY INFORMATION

  • WHAT ARE YOUR ADOPTION PREFERENCES

  • EXPENSE AFFIDAVIT

  • If you believe that you may need financial assistance during your pregnancy, this form must be completed. We can not guarantee that your state laws will permit the opportunity for you to receive aid, or for the amount you are requesting.
  • WHAT MONTHLY EXPENSES WILL YOU NEED HELP WITH (enter amounts)

  • I understand that it is illegal to receive financial benefits from any prospective adoptive family without the intention of completing an adoption. I further understand that it is illegal to receive financial benefits from more than one prospective adoptive family and/or adoption entity at the same time.
  • COUNSELING AFFIDAVIT

  • Abby’s One True Gift Adoptions is a licensed child placing agency and is required by state law to notify all prospective Birthparents that counseling is available.

    Iowa statute 108.9(2) Services to birth families. An agency which offers services to birth parents who are considering relinquishing a child for adoption shall provide a minimum of three hours of counseling, or any additional hours of counseling necessary to assist the parents in making an informed decision regarding their child’s adoption, consistent with the child’s best interest. The counseling of the birth parents shall begin when the birth parents begin the intake process.

  • CRIMINAL BACKGROUND SEARCH AUTHORIZATION

  • Abby’s One True Gift Adoptions is a licensed child placing agency and is required by the State of Iowa to EITHER, conduct a criminal background search on all prospective birthmothers OR, receive notification from the prospective birthmother that they do not wish to have a criminal background search conducted by the agency. A criminal background search is not a requirement by federal adoption laws and if you elect to not allow Abby’s One True Gift Adoptions to conduct a criminal background search, it will not prohibit you from placing your child for adoption nor will it prohibit you from working with our agency to achieve your adoption goals.
  • MEDICAL RECORD AUTHORIZATION

  • Per the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I hereby authorize any medical practitioner or facility or related entity to give Abby’s One True Gift Adoptions Inc. any of the following;

    Verification of any documentation presented to them by me which substantiates my current condition as it relates to pregnancy.

    Medical information, records and data about me related to pregnancy.

    The entire medical file for the last three years not excluding; medical information, records and data, alcohol and drug use and/or abuse, and drugs prescribed.

    Information, records and data about me relating to mental illness, other than psychotherapy notes.

  • AGREEMENT

  • ADOPTION: I understand that Abby’s One True Gift Adoptions Inc. will process a legal and ethical adoption for me, my child (children), and the family I select. I understand I have the right to select or reject any adoptive parents, and that Abby’s One True Gift Adoptions Inc. does not make decisions concerning my selection of adoptive parents unless I specifically state otherwise.

    REPRESENTATION: I am not currently associated with any other entity, formally or informally, who might assist me to locate a family to adopt my child (children). I am not currently communicating with any prospective adoptive parents concerning the adoption of my child (children). I understand that it is illegal to arrange with multiple prospective parents at the same time in the interest of adopting my child and/or receive financial benefits from multiple prospective families at the same time during my pregnancy.

    WAIVER OF CONFIDENTIALITY: I hereby authorize Abby’s One True Gift Adoptions Inc. and any of its representatives to share all information provided by me with any prospective adoptive parents who may be interested in adopting my child (children), or any representative acting on their behalf, or on my behalf, and with any professional otherwise connected with the adoption plan.

    FINANCIAL ASSISTANCE: I understand that dependent on the laws of my state and the state the adoptive parents reside in, I may not be permitted to receive financial assistance from adoptive parents. I understand that it is illegal to receive financial benefits from any prospective adoptive family without the intention of completing an adoption.

    ACKNOWLEDGEMENT: I acknowledge that all information provided (written and/or spoken) to Abby’s One True Gift Adoptions is factual and accurate to the best of my knowledge.

  • SIGNATURE