Birth Parent Application

Birth Parent Application

If you're considering placing a child for adoption, this is the first step.

Filling out this application lets us know you're ready to start the adoption process. Your team is here to support you. Once you submit your application, a member of our team will reach out to you quickly, usually the same day. We'll talk through your adoption plan and options.

Important! This application is for anyone seeking to place a child for adoption. If you aren't sure that adoption is the right choice for you, please call us to discuss your options before completing this form.

Birth Mother Information

In an emergency, who can we contact?

Personal Information

Pregnancy Information

History of drug use

Adoptive Family Matching

(I understand that my adoptive family preferences may change as I make my adoption plan.)

Post-adoption contact preferences

I give Global Child Adoption Agency/Alternative Options my consent to:

Birth Parent Service Agreement

I am interested in placing my child, born/expected to be born on with Global Child Adoption Agency/Alternative Options ("Global Child Adoption Agency") for the purpose of adoption.

I understand Global Child Adoption Agency has agreed to provide services to me related to my adoption plan. I have filled out Global Child Adoption Agency's Birth Parent Application to the best of my knowledge, and Global Child Adoption Agency has explained in full the services which can be provided to me. I understand that services are provided on a case-by-case basis, but that I will have access to all services Global Child Adoption Agency could provide to me.

Authorization to Receive and Disclose Protected Health Information

Please release to Global Child Adoption Agency/Alternative Options and Services for Children ("Global Child Adoption Agency"), or any employee or agent of Global Child Adoption Agency, 9561 South 700 East, Suite 101, Sandy, Utah, 84070, copies of all my medical records, including, but not limited to charts, notes, evaluations, test results, invoices and similar documents that you have in your possession as are described below.

Release of Identifying Information

I have contacted Global Child Adoption Agency/Alternative Options and Services for Children ("Global Child Adoption Agency") for the purpose of possibly placing my child for adoption.

Should I choose not to place my child for adoption, I understand that it may become necessary for Global Child Adoption Agency to provide my name, home address, home telephone number and social security number to medical providers so that arrangements can be made for my medical bills to be paid.

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