Agreement Between Agency and Birth MotherThis Agreement is between Adoption Choices of Oklahoma, a licensed adoption agency, acting as agent for the adoptive parent(s), hereinafter referred to as “Agency”, and (fill in name) hereinafter referred to as “Birth Mother”. Agency, acting as agent for the adoptive parent(s), agrees to provide Birth Mother with the following care and services: counseling, court awarded necessary living expenses, confidentiality, protection of records, and legal fees.(Required)Last 4 of Social Security Number:(Required)OTHER COVERED COSTSPlease check box to acknowledge.(Required) Care and services provided by Agency, acting as agent for the adoptive parent(s), may include: a) counseling sessions; b) living costs; c) legal fees related to the adoption proceeding; and d) case worker fees.BIRTH MOTHER RESPONSIBILITIESPlease check box to acknowledge.(Required) Birth Mother hereby agrees to permit Agency, as agent for the adoptive parent(s), sole and exclusive right to place her child for adoption.Please check box to acknowledge.(Required) Should Birth Mother make the decision to parent the child, she agrees to assume full responsibility for paying all costs incurred by Agency, acting as agent for the adoptive parent(s), which expenses were paid on behalf of Birth Mother and/or the child. The expenses shall include, but not be limited to, Birth Mother’s living expenses, attorney fees for agency, adoptive parent(s), and birth parents, as well as any fees paid to any case worker or counselor working with Birth Mother. Should Birth Mother make the decision to parent the child, or work with another agency or law firm, this Agreement is terminated, except for the portions regarding repayment of expenses by Birth Mother.Please check box to acknowledge.(Required) Birth Mother understands and acknowledges that if the pregnancy is terminated by miscarriage or medical necessity, or if the child is stillborn at birth, Agency, acting as agent for the adoptive parent(s), will no longer be responsible for any of Birth Mother’s expenses as listed above, and this Agreement shall be terminated.MEDICAID COVERAGEPlease check box to acknowledge.(Required) Birth Mother understands and acknowledges that it is her responsibility to apply for Medicaid coverage, and to give Medicaid the correct information in a timely fashion to process her application and acquire Medicaid coverage. If Birth Mother has told Agency she is covered by Medicaid or private insurance, or if Birth Mother should qualify for Medicaid coverage but does not cooperate with Medicaid to have coverage put into effect or otherwise fails to obtain coverage that she is qualified for, she understands and acknowledges that she will be responsible for any medical bills that should have been covered by Medicaid, and that Agency will not pay those bills.BIRTH MOTHER’S STATEMENTPlease check box to acknowledge.(Required) I realize that should I make the decision to parent my child, I agree to repay Agency, acting as agent for the adoptive parent(s), in full for all costs incurred by Agency on my behalf or that of my child.Please check box to acknowledge.(Required) I fully understand that the decision to relinquish my child is a decision only I can make. This decision is to be made without coercion, influence, or inducement from anyone. I have voluntarily decided to work with Agency, acting as agent for the adoptive parent(s), during my pregnancy, because it is my intention at this time to make an adoption plan. If at any time I change my mind about proceeding with adoption planning, I will immediately notify Agency, acting as agent for the adoptive parent(s), of the change in plans.Please check box to acknowledge.(Required) I agree to allow Agency to take a picture of me, which may be shown to prospective adoptive parent(s) prior to matching me with a family, and which may be given to authorities if any criminal activity occurs while I am working with Agency. If I have provided my Facebook name to Agency, I understand that Agency staff may look at my Facebook profile and/or pictures. I also hereby consent to and give permission for the identifying information and any other pictures I have provided to Agency, as well as all medical information and/or other information in my file, to be given to the adoptive parent, their attorney, and/or other adoption professionals as needed, unless I specifically state otherwise in writing. Further, I understand that after placement of the child, if I suffer from any ongoing health conditions and/or concerns, I should notify Agency so the adoptive parent(s) can be notified. In the event of my death, Agency will notify the adoptive parent(s) and inform them of the cause of my death.Please check box to acknowledge.(Required) I fully understand that Agency, acting as agent for the adoptive parent(s), is not a charitable or welfare organization established to provide free care for expectant mothers who are planning to parent their child after delivery. I hereby understand that I will have my own attorney at my consent hearing, who will be provided by Agency, and I hereby consent that Agency or the adoptive parent(s) will pay for this representation on my behalf. I further understand that my attorney will only represent me in this matter and will not represent Agency or the adoptive parent(s). I understand and acknowledge that Virginia L. Frank is the attorney for Agency and does not and will not represent me.Please check box to acknowledge.(Required) I further understand that accepting financial assistance from more than one adoption agency and/or adoptive family simultaneously, or if I accept financial assistance but am not actually pregnant or do not actually intend to complete an adoption plan, may be considered fraud, and could result in criminal or civil prosecution.Please check box to acknowledge.(Required) I fully understand all of the above and foregoing information. I have asked any questions I may have and agree to abide by this Agreement.Birth Mother's Signature:(Required)Today's Date:(Required) MM slash DD slash YYYY Check box to acknowledge:(Required) By submitting this form, you consent to the transmission of your information over the internet and understand the associated risks.