Birth Mother/Parents Preferred Placement Questionnaire

Date: 
2009-06-01

Birth Mother/Parents Preferred Placement Questionnaire

 
 

You are making a plan for your baby’s future. In planning for that future, the most important decision you will make is who will be your child’s adoptive family. Our role is to assist you to find the adoptive family that you would like to raise your child. We are asking you to guide us in that search by responding to the following questions to the best of your ability so that we can understand what kinds of families you would consider “right” for your child. We ask that you take your time and consider each question fully and provide the broadest range of possibilities you would consider. The possibilities that you have established will be all of the information we need to find a family or families who will be acceptable placement options for your child.

 

Your counselor can help you with this process by allowing you the freedom to share your thoughts in a confidential and safe environment. Please take your time and consider each question thoughtfully.

 
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People who adopt children as a way to build their family are just like everyone else: they come in all different sizes, shapes, ethnicities, ages, genders, religions, and are from a variety of geographical locations.

 

The purpose of this questionnaire is to help you to consider what kinds of families you could picture in the placement of your child. There are no right or wrong answers. This is all about what you want for the future of your child. It is important that you, as the Birth Parent, answer all of these questions yourself and not be guided or influenced in any way by any person.  

 

As you read each question and discuss; please complete the answers in your own handwriting.

 

No one else should fill in this questionnaire for you.

 
Please sign and date the bottom of every page.
 

You will be presented with one or more prospective adoptive families who have an approved home study and who are qualified to adopt according to the rules, regulations and laws for adoption in their state or country of residence. 

 
  1. What do you feel is the definition of “Family” ?
 

      Statement: I think that a family may be a married couple or a single person.

 

How do you feel about that? _____________________________________

 

Are you okay with a married couple? _____ A single parent? ______

 

Is either one acceptable to you? _________ or only one? ________

     
Comments:______________________________________________________
 
 
_______________________________________                ________________________________
Birth Parent                                             Date                       Witness                                                   Date
 
 
 
 
  1. Single parent – if you are seeking a married couple only, please skip to question # 4
 

      There are many single people who adopt children. They have not married for one reason or another         but they love children and they want to parent children. They are at a good stage in their lives where        they have received their education and have good jobs and are stable economically. They are ready        to be parents and have chosen to build their family through adoption. Today both single men and           single women are parenting children and doing a very good job.

 

      Some single parents live alone and parent their children alone. The child is the most important      person in their lives and they are able to give the child or children they adopt their full attention.         They usually have a good support group around them and often the full support of their family    members.

 

      Would you consider a single woman as an adoptive parent for your            child?________________________

 

      Would you consider a single man as an adoptive parent for your child? ________________________

 
  1. Partner Relationships
 

      Some single people live with partners. These are relationships of two people who are committed to           each other but are not married. When such a couple desires to adopt a child, only one of them can be         the legal adoptive parent. In such a family the child would have one legal parent but would be parented by both of the partners in the relationship. In some jurisdictions, the partner may also adopt    the child as a full and legal parent, creating a legal two-parent family.

 

      Some relationships are a man and a woman who are not married.

 

      Would you consider an unmarried couple (man and woman) as an adoptive family for your child?       _________________________________________________

 

      `Some single people live with partners of the same gender.

 

Would you consider a same gender couple as an adoptive family for your child?  

 

      _______Female Couple        ______Male Couple        __________Either Male or Female Couple

 

              I would not consider a partner relationship for an adoptive placement for my child.

            _____________________________________________          
             
 
 
 
_______________________________________                ________________________________
Birth Parent                                  Date                                   Witness                                                   Date
 
 
 
 
 
 
 
 
 
 
 

 4. Number of children living in the home of the adoptive family:

 

      Do you have strong feelings about the number of children already living in the adoptive family?

 

      _______No,

 

      _______Yes, because_____________________________________________________________

 

      Do you want your child to be the only child or to have siblings?                 

 
      __________________________________________________________________
     
      Comment:       ________________________________________________________________________     
 
5.  Religion:
 

      Do you have any religious preference for your baby?

     

Yes, I would like my child to be raised in/as __________________________________________          

 

      No ____________________________________________________________________________

 

It does not matter. ________________________________________________________________

     
Comment:
      ________________________________________________________________________      ________________________________________________________________________
 
6.   Ethnicity: 
 

      What is your ethnicity? _______________________________________

 

      What is the ethnicity of your baby’s other birth parent? __________________________

 

      Is it important to you that the adoptive parents are the same ethnicity as you and/or the other parent?

 
      Comment:________________________________________________________________________
 

Are you open to placing your child in adoptive families of other ethnicities? ___________________

 

What adoptive family composition would be acceptable for you? Circle all that would apply.

 

Caucasian       Asian               African/African-American      Hispanic         Multi-ethnic

 

Other               It does not matter to me.

     

Comment: _________________________________________________________________

     
_______________________________________                ________________________________
Birth Parent                                             Date                       Witness                                                   Date

7.   Geographic location: “Where does the adoptive family call home?”

 

      The family who adopts your baby might live anywhere.

 

      They could live in the same city as you.

 

      They could live in your state of residence.

 

      They could live anywhere in the United States

 

      They could live in another country.

 

      Remember, that families often move from place to place during their lifetime.

 

      Does the geographical location of the adoptive family matter to you? ______Yes _____No

 
      Comment:_____________________________________________________________________         
 

      Because adoptive families can live anywhere in the world, that also means that they can be citizens          of another country.

 

      Did you know that your child will always keep his/her US Citizenship even if he/she is adopted by a        family who are citizens of another country?

 

      Did you know that many non-US countries speak English as a second language?

 

      Would you consider non-US Citizens as a possible adoptive placement for your child?     

 

Circle your answer: Yes.     No.

      

            Comment:_________________________________________________________________     
 
  1. Have you thought about the question of “openness”? _____Yes _____No
 

      What would you ideally like in an agreement for openness?

      ____________________________________________________________________
      __________________________________________________________________
 

      What would you be willing to accept?

      _________________________________________________________________
      _________________________________________________________________
 

10. After considering all of the different possibilities, what is the one most important thingyou are  looking for in any prospective adoptive family for your baby?

      __________________________________________________________________      __________________________________________________________________      __________________________________________________________________
 
 
 
_______________________________________                ________________________________
Birth Parent                                             Date                       Witness                                                   Date
 
 

            What is the one thing most important thing that you do not want?

      _________________________________________________________________________________      _________________________________________________________________________________      _________________________________________________________________________________
 
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After we review your Birth Mother/Parent Preferred Placement Questionnaire and your counselor’s report, we will provide you with profiles of families who match the information you have provided during your counseling session and noted on this questionnaire. Remember that the adoptive family must also accept your profile and the baby’s profile. Not every adoptive family accepts every baby. The adoptive family must also consider everything that could be a risk factor, which includes health issues and legal issues. The match between the Birth Mother/Parents and the adoptive parents must be done very carefully on both sides. Our number one responsibility to you and to the baby is to assist you in making the best placement decision possible so that your baby will grow up in a loving and committed family. You will be presented adoptive family profiles as determined by your preferences. It is from these adoptive family profiles that you will make the decision for the best placement option for your child. 

 
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I, ____________________________________________(Print your full legal name) am the birth mother/father of the child to be placed for adoption. I do hereby swear that I completed this questionnaire under the supervision of an independent witness freely, willingly and without anyone influencing my answers.

 
 ___ _______________________________________       

Birth Parent                                  Date                                              

 
 

I, ____________________________________________(Print your full legal name) am the independent witness (not the notary) who assisted this birth parent with completing this questionnaire without my influence or any other person’s influence to answer these questions freely, willingly and honestly.

 
 
 
___________________________________
Witness                                                         Date
 
 
 
Sworn to and subscribed to
Before me this ____day of ____________, 200      
 
 
 
 
______________________________________
Notary Public
 
 

 

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