Birthmother Application

There is a choice…

Thank you for starting the application process. We realize the decision to place a child for adoption is one of the most difficult you have ever made, and we are here to guide you through this challenging time. This is a secure form. All information is submitted confidentially.

Please leave us your phone number. We would very much like to speak with you directly. We will call you and answer any questions you have. If you do not answer the phone, we will only leave our first name and our phone number as a message. We will never tell anyone else why we are calling or that we are an adoption agency. We will always keep your information private.

Once we receive this application, we will mail you medical release forms for you to sign. We will also need a proof of pregnancy - a note from the doctor or clinic stating that you are pregnant, or copies of ultrasound results. Feel free to fax the proof of pregnancy to us at (207) 655-1249.

This form is for birthmothers looking to place a child for adoption only. If you wish to adopt a child, please visit www.storksearch.org.

Birthmother Personal Information
Yes  No
Yes  No
French  Irish  Hispanic 
Greek  Indian  English 
German  Dutch  Scottish 
Spanish  Polish  Russian 
Middle Eastern 

It is important for us to know if you are a member of any Native American Indian Tribe. Please answer the following question to the best of your knowledge: Are you a member of any Native American Indian tribe? Yes  No

Left-handed  Right-handed 
Your Baby
Employment and Education
From:  To: 
Family
Name 
Lives with  Age 
Name 
Lives with  Age 
Name 
Lives with  Age 
Adoption Choices
Yes  No
Age Range
Yes  No
Birthfather
Birth Date (mm/dd/yy)
Left-handed  Right-handed 
French  Irish  Hispanic 
Greek  Indian  English 
German  Dutch  Scottish 
Spanish  Polish  Russian 
Middle Eastern 
Criminal Background
Yes  No
Misdemeanor  Felony  Drug-related  Other 
Health
Condition Yes No You Relative Type/Treatment
Allergies Yes No You Relative Type/Treatment
Condition Yes No You Relative Type/Treatment
Blood Conditions Yes No You Relative Type/Treatment
Condition Yes No You Relative Type/Treatment
Diseases Yes No You Relative Type/Treatment
Drug Use or Addiction Yes No You Relative Type/Treatment
Condition Yes No You Relative Type/Treatment