Best Adoption Agency Massachusetts | A Full Circle Adoptions

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HOME
I’M PREGNANT
- Free Adoption Help
- Intake Forms
WAITING FAMILIES
HOPING TO ADOPT
RESOURCES
EVENTS
ABOUT
CONTACT US

Parent & Child (already born) Background

Step 1 of 12 - Page 1

Mother
Full Name*
Your Place of Birth
Your Date of Birth*
MM slash DD slash YYYY
Phone Number: Cell*
Phone Number: Work
Email*
Enter Email Confirm Email
Driver’s License
State
Number
Present Address
Number & Street*
City*
State*
Zip*
Physical description
Height*
Eye Color*
Hair Color*
Your current weight*
Skin color/race/ethnicity*
Describe your Personality*
What is your family’s ethnic heritage? (French, Irish, Italian, Puerto Rican, Mexican, etc.)*
Are you or either of your parents a member of a Native American (Indian) tribe*
- Yes
- No
If yes, please specify to the best of your knowledge the tribe(s):
and which relatives are or were a member of a tribe:

EDUCATION
Did you complete High School?
- Yes
- No
If no, last grade completed
Name of School
Subjects you liked during high school
Talents, hobbies, interests
Additional education (e.g. College/Vocational)
MARITAL STATUS
Marital Status*
- Single
- Divorced
- Married
- Separated
- Widowed
- Not Married
Name of your spouse*
Name of your former spouse*
Date of Divorce
Month
Day
Year
Date of Marriage
Month
Day
Year
Is your spouse the father of your child?*
- Yes
- No
Is your spouse aware of the adoption plan?*
- Yes
- No
Does your spouse agree with your plans?*
- Yes
- No
RELIGION
Do you consider yourself religious?
- Yes
- No
If so, what religion or name of church attended

CHILD
Child's Name*
Child's Date of Birth*
MM slash DD slash YYYY
Your Child's Doctor’s Name*
Dr.'s Phone
Date of child's last visit*
MM slash DD slash YYYY
Dr.'s Clinic Name & Address
Does your child have health insurance?*
- Yes
- No
If yes, what type of Insurance?*
Insurance card number:
Has your child been diagnosed with any medical/health conditions?
- Yes
- No
If yes, please explain
Does your child have any psychological or emotional conditions (including autism,or anxiety)?
- Yes
- No
If yes, please explain
Does the child's doctor know you are considering adoption?*
- Yes
- No
Are you parenting this child?*
- Yes
- No
Who is parenting this child?*
Are you parenting other children?*
- Yes
- No
What are their names and current ages:*
Were there any problems with this pregnancy?*
- No
- Yes
If yes, please give details*
Were there any problems with any prior pregnancies, if applicable?*
- No
- Yes
- N/A
If yes, please give details*
FATHER OF BABY
Name of the father of your child? If unsure, please name possible fathers.*
His Phone #
Does he agree with an adoption plan?*
- Yes
- No
If no, is he involved with you?*
- Yes
- No
What is his age?*
Height?
Hair color?
Eye Color?
Skin Color/Race/Ethnicity?*
What are your reasons for making an adoption plan for your child?*

YOUR PREFERENCES REGARDING SELECTION OF AN ADOPTIVE FAMILY
Do you have a religious preference for an adoptive family?*
Please check all prospective adoptive families who you are open to considering:*
- Select All
- Couples
- Heterosexual couple
- Lesbian couple
- Gay male couple
- Single parents
- Heterosexual single mother
- Lesbian single mother
- Gay male single father
Would you like to receive photos and updates regarding your child?*
- Yes
- No
- Unsure
Would you like to have visits with your child?*
- Yes
- No
- Unsure
DRUGS & SUBSTANCES TAKEN DURING YOUR PREGNANCY
Do you smoke cigarettes?*
- No
- Yes
How many per day?*
*Non-Prescription Medications (including aspirin, nose drops, diet pills)*
- Yes
- No
Please explain what type and for what condition?*
*Prescription Medications (including birth control pills, acne treatments, oxycodone):*
- Yes
- No
If yes, please explain what type and for what condition?*
*Alcohol*
- Yes
- No
How Much?*
*Marijuana*
- Yes
- No
How Much and how often?*
*Opioids (hydrocodone, oxycodone, fentanyl)*
- Yes
- No
What type? How often?*
*LSD*
- Yes
- No
How Much and how often?*

*Heroin*
- Yes
- No
How Much and how often?*
*Methadone*
- Yes
- No
How Much and how often?*
*Amphetamines (Uppers)*
- Yes
- No
How much and how often?*
*Methamphetamines*
- Yes
- No
How much and how often?*
*Barbiturates (Downers)*
- Yes
- No
How much and how often?*
*Crack*
- Yes
- No
How much and how often?*
*Cocaine*
- Yes
- No
How much and how often?*
*Tranquilizers*
- Yes
- No
What kind and how often?*
*Anti-Depressants*
- Yes
- No
What kind?*
*Anti-Psychotics*
- Yes
- No
What kind?*
Have you received in-patient or outpatient drug/alcohol abuse treatment?*
- Yes
- No
If yes, where?*

FAMILY MEDICAL HISTORY
Please indicate by checking “Yes” or “No” if YOU or any BIOLOGICAL RELATIVES have the following conditions
VISUAL PROBLEMS
Glasses (please specify if near/far sighted, astigmatism)*
- Yes
- No
Which relatives (including yourself)*
Different color eyes*
- Yes
- No
Which relatives (including yourself)*
Blindness from Glaucoma, cataracts, etc.*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Color blindness*
- Yes
- No
Which relatives (including yourself)*
Lazy eye*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Retinitis Pigmentosa*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Strabismus*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
HEARING PROBLEMS
Frequent earaches*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Frequent ear infection*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Deafness: Full or Partial*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Tubes*
- Yes
- No
Which relatives (including yourself)*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
SPEECH PROBLEMS
Stutter*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Lisp*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Speech therapy*
- Yes
- No
Which relatives (including yourself)*
What is the speech therapy focused on?*
Other (describe):*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

DENTAL PROBLEMS
Missing or extra teeth*
- Yes
- No
Which relatives (including yourself)*
Receding chin*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Protruding jaw/teeth*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Braces*
- Yes
- No
Which relatives (including yourself)*
What age? Specific diagnosis & severity*
TMJ*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe):*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
FACIAL CONDITIONS
Cleft Lip*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Cleft palate*
- Yes
- No
Which relatives (including yourself)*
treatment, specific diagnosis & severity*
Other (describe):*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
SKELETAL SYSTEM CONDITIONS
Scoliosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Spina bifida*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Osteoporosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Missing or extra fingers*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Missing, extra or webbed toes*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Feet turning out/turning out*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Spurs/bunions*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Club foot*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Different length legs*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Congenital hip*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Shallow hip socket*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Brittleness of bones*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

RESPIRATORY PROBLEMS
Chronic sinusitis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Tonsils/adenoid issues*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Chronic runny nose*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Emphysema*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Bronchitis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Asthma*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Allergies/Hay Fever*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Pneumonia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Cystic fibrosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
LEARNING CHALLENGES
Learning disability*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Special education*
- Yes
- No
Which relatives (including yourself)*
Specific diagnosis, services, & severity*
Dyslexia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
ADD/ADHD*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Autism*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Developmental disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

EMOTIONAL / PSYCHOLOGICAL / PSYCHIATRIC ISSUES
Anxiety*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Depression*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Bipolar disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Eating disorder (i.e. Anorexia, bulimia, over-eating)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
OCD (obsessive/compulsive disorder)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Schizophrenia/hearing voices*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Psychiatric hospitalization (dates and name of hospitals)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other: (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
SUBSTANCE ABUSE
Heavy drinking*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, & severity*
Alcoholism*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Drug abuse (specify which drugs)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
SKIN DISORDERS
Birthmarks*
- Yes
- No
Which relatives (including yourself)*
Eczema*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Psoriasis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Vitiligo*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Patches of skin of different color*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Albinism*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

CIRCULATORY DISORDERS
Varicose veins*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Hypertension*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
High cholesterol*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Stroke*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Aneurysm*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
NEUROLOGICAL DISORDERS
Epilepsy*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Seizure disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Cerebral palsy*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Bulbar Palsy*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Alzheimer’s or Dementia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Parkinson’s Disease*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Huntington’s Chorea*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Microcephalus or Hydrocephalus*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
A.L.S. – Lou Gehrig’s Disease*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
BLOOD DISORDERS
Anemia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Hemophilia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Leukemia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Sickle cell anemia*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

ENDOCRINE SYSTEM DISORDERS
Diabetes - Type 1 or Type 2 (early or late onset)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
GASTROINTESTINAL SYSTEM DISORDERS
Pyloric Stenosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Celiac Disease*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Gastroenteritis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Inflammatory bowel*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Colitis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Polyps or Colon cancer*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Crohn’s Disease*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Ulcers*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
AUTOIMMUNE DISORDERS
Lupus*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Rheumatoid arthritis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Graves Disease*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Multiple sclerosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Guillain-Barre syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
MUSCULAR SYSTEM DISORDERS
Muscular dystrophy*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Neuromuscular disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
SLEEP DISORDERS
Narcolepsy*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Sleep apnea*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
HORMONE DISORDERS
Thyroid disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Growth disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*

REPRODUCTIVE SYSTEM
Multiple births (twins, triplets, etc.)*
- Yes
- No
Which relatives (including yourself)*
If yes, please give details*
Pre-term labor*
- Yes
- No
Which relatives (including yourself)*
If yes, please give details*
Breech birth/Caesarian*
- Yes
- No
Which relatives (including yourself)*
If yes, please give details*
Ectopic pregnancy*
- Yes
- No
Which relatives (including yourself)*
If yes, please give details*
Endometriosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Polycystic Ovary Syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Premenstrual Dysphoric Disorder*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Born Intersex*
- Yes
- No
Which relatives (including yourself)*
Other (describe):*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
GENETIC SYNDROMES & DISORDERS
Down Syndrome*
- Yes
- No
Which relatives (including yourself)*
Fragile X Syndrome*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Klinefelter Syndrome*
- Yes
- No
Which relatives (including yourself)*
Treatment, specific diagnosis & severity*
Prader-Willi Syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Rett Syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Angelman Syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Neurofibromatosis*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
PKU*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Marfan Syndrome*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
INFECTIOUS DISEASES
HIV*
- Yes
- No
Which relatives (including yourself)*
Age of diagnosis & treatment*
Hepatitis A B C D E*
- Yes
- No
Which relatives (including yourself)*
Age of diagnosis, treatment, specific diagnosis & severity*
Herpes*
- Yes
- No
Which relatives (including yourself)*
Age of diagnosis, treatment, specific diagnosis & severity*
Tuberculosis*
- Yes
- No
Which relatives (including yourself)*
Age of diagnosis, treatment, specific diagnosis & severity*
Other (describe)*
- Yes
- No
Which relatives (including yourself)*
Age of onset, treatment, specific diagnosis & severity*
CANCER
Cancer*
- Yes
- No
Which relatives (including yourself)*
What type(s) of cancer, age of onset, & treatment*
ANY OTHER CONDITIONS
Please use this space to share any additional family health information:
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Western MA Office
8 Bridge Street
Northampton, MA 01060

Call: 800-452-3678
Text: 413-552-9168

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Our Credentials

Full Circle Adoptions is a fully licensed Massachusetts and Maine domestic infant adoption agency. Though we specialize in domestic adoption, we also offer home studies and post-placement services for international adoptions. The agency provides comprehensive adoptive services for expectant parents, prospective adoptive families, and children throughout the United States.

Upcoming Orientations

Adoptive Parents Orientation
January 10 @ 9:00 am - 11:00 am
Adoptive Parents Orientation
January 26 @ 5:00 pm - 7:00 pm
Adoptive Parents Orientation
February 9 @ 5:00 pm - 7:00 pm

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Parent & Child (already born) Background

Step 1 of 12 - Page 1

Mother

Driver’s License

Present Address

Physical description

EDUCATION

MARITAL STATUS

RELIGION

CHILD

FATHER OF BABY

YOUR PREFERENCES REGARDING SELECTION OF AN ADOPTIVE FAMILY

DRUGS & SUBSTANCES TAKEN DURING YOUR PREGNANCY

FAMILY MEDICAL HISTORY

VISUAL PROBLEMS

HEARING PROBLEMS

SPEECH PROBLEMS

DENTAL PROBLEMS

FACIAL CONDITIONS

SKELETAL SYSTEM CONDITIONS

RESPIRATORY PROBLEMS

LEARNING CHALLENGES

EMOTIONAL / PSYCHOLOGICAL / PSYCHIATRIC ISSUES

SUBSTANCE ABUSE

SKIN DISORDERS

CIRCULATORY DISORDERS

NEUROLOGICAL DISORDERS

BLOOD DISORDERS

ENDOCRINE SYSTEM DISORDERS

GASTROINTESTINAL SYSTEM DISORDERS

AUTOIMMUNE DISORDERS

MUSCULAR SYSTEM DISORDERS

SLEEP DISORDERS

HORMONE DISORDERS

REPRODUCTIVE SYSTEM

GENETIC SYNDROMES & DISORDERS

INFECTIOUS DISEASES

CANCER

ANY OTHER CONDITIONS

Our Credentials

Upcoming Orientations

Adoptive Parents Orientation

Adoptive Parents Orientation

Adoptive Parents Orientation

Let’s Connect