Birth Mother IntakeIDENTIFYING INFORMATION OF BIRTH MOTHERFull Legal Name: First Middle Last Other names used (such as maiden name):Is this adoption confidential? Yes NoCell Phone Number:Home Phone Number:Email: Facebook name:Age and Date of Birth:Religion:Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Apartment Name (if applicable):Cross Streets:Landmark(s):Employer:Work phone:Days/Hours worked:Monthly income:Emergency contact name and phone number:Is he/she aware of adoption? Yes No Will beLast 4 of SSN:Place of Birth:Race of Birth Mother:Native American Indian? Yes NoAre you or any member of your family registered? Yes NoWhich tribe:Are you: French Irish Greek Italian English German Dutch Scottish Scandinavian Hispanic OtherDefine other:Race of Child:MEDICALDue date: MM slash DD slash YYYY Has the due date been confirmed? Yes NoIf no when was your first day of your last menstrual period?Pregnancy calculator (wheel) due date is: MM slash DD slash YYYY Calculated by:When did you find out you were pregnant (approximate date)?Have you had regular pre-natal care? Yes NoWhen did you start pre-natal care?Have you had an ultrasound? Yes NoIf yes, date: MM slash DD slash YYYY Sex of baby? Male Female UnknownAmniocentesis (if over 35 years) results:Do you have any medical coverage? Yes No Will be Have applied Don't qualifyIf yes, through Medicaid or private insurance? Medicaid PrivateIf private insurance, what company?Do you have transportation to and from your Doctor? Yes NoWho is your doctor?Phone number:Address:When was your last appointment?Next appointment:Is he/she aware of the adoption?What hospital are you using?Do you have any medical problems? Describe:Have you had an HIV Test? Yes NoIf yes, when and where?Have you ever received any psychiatric counseling / treatment? Yes NoHow long? At what age? Inpatient or Outpatient?Diagnosis: Medication prescribed:Is there any mental illness in your family? Yes NoIf yes who?Height:Pre-pregnancy weight:Eye color: Brown Green Blue HazelNatural hair color: Black Brown Blond AuburnHair texture: Wavy Curly StraightSkin complexion: Fair Medium Olive Dark TanBody Build: Small Medium Big BonedAre you a Twin: Yes NoIdentical or Fraternal Identical FraternalIs your twin a male or female? Identical FraternalDo you have other children? Yes NoDo they live with you? Yes NoIf not, who do they live with?What is their father’s name?What are their age(s) and gender?What is their health history?Have you ever considered adoption during a previous pregnancy? Yes NoWhat was your previous labor like?Total pregnancies:Total miscarriages:Total abortions:PERSONALUntitled Never been married Married Separated DivorcedWhen and where?Husband’s name:Address (if different than yours):Home phone:Work phone:Employer:When and where:Are you a member or eligible for membership of a Native American Tribe? Yes NoIf yes, are you registered? And what tribe?What kind of education do you have?Do you plan to continue your education? Yes NoIf yes, what is your major?How did you learn about Adoption Choices of Oklahoma: Doctor’s Office Google Hospital or Clinic Referral Facebook or Instagram Thrifty Pharmacy Bags Parents.com Referral OtherName of Doctor's officeWhat words did you use in your search on Google?Name of hospital or clinic:Who:Specify other:Anything else you want to tell us:Date personal interview scheduled:Other information: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.