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- Alyssa A. Jacobs
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Private Adoption Information Sheet

Adoptive Parent(s)

Adoptive Parent 1

Current Legal Name*

First Middle Last

Name as appears on Birth Certificate*

First Middle Last

Do you use a title with your name such as Dr. or Rev.?*

Yes

No

Title*

Date of Birth*

MM slash DD slash YYYY

Place of Birth*

Social Security Number*

Cell Phone Number*

Email Address*

Is there an additional parent?*

Yes

No

Adoptive Parent 2

Current Legal Name*

First Middle Last

Name as appears on Birth Certificate*

First Middle Last

Do you use a title with your name such as Dr. or Rev.?*

Yes

No

Title*

Date of Birth*

MM slash DD slash YYYY

Place of Birth*

Social Security Number*

Cell Phone Number*

Email Address (Must be different from email above. We use DocuSign for final documents which requires different emails for each parent.)*

Additional Information Concerning Adoptive Parent(s)

Address at the time of the birth of child*

Street Address Address Line 2 City State ZIP Code

County of Residence at the Time of Birth of Child*

Current Mailing Address*

Street Address Address Line 2 City State ZIP Code

Is your address within city limits?*

Yes

No

Names and ages of children living in home, including child to be adopted*

Information on child to be adopted

Name birth mother will put on birth certificate at the time of birth*

First Middle Last

Name that you want the child to have*

First Middle Last

Date of Birth or Due Date*

MM slash DD slash YYYY

Gender*

Female

Male

Place of Birth*

Hospital of Birth (if known)

If child is already born, date that child was placed with you*

MM slash DD slash YYYY

Birth Mother of Child

Birth Mother's Current Legal Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Phone Number*

Current Address*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Is Birth Mother Married?*

Yes

No

Was she married at the time of conception or during her pregnancy?*

Yes

No

Full Legal Name of Husband*

First Middle Last

Husband's Date of Birth*

MM slash DD slash YYYY

Husband's Current Address*

Street Address Address Line 2 City State ZIP Code

Husband's County of Residence*

Birth Father

Is the Birth Father’s identity known?*

Yes

No

Full Legal Name of Birth Father*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Current Address*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Is the Birth Father married to the Birth Mother?*

Yes

No

Is the Birth Father aware of the pregnancy?*

Yes

No

Is the Birth Father in a relationship with or supported the Birth Mother?*

Yes

No

Is the Birth Father involved in the adoption process?*

Yes

No

Home Study Provider

Name of social worker who did your home study*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Human Check

Δ

Location

Our Clients

“The adoption team was available to answer our questions quickly and made us feel comfortable in what can be, at times, an incredibly stressful situation. They helped us prepare for everything and really lead us in the right direction. We honestly don’t know where our family would be without all of their hard work, dedication, and passion for helping to create “forever families." - Travis & Toby Clayton

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The articles presented on these pages may not be applicable to your particular legal situation. You should consult with an attorney regarding your specific legal situation.

Brown Pruitt Wambsganss Dean Forman & Moore, P.C. gathers, stores, and electronically transmits medical records (Protected Health Information or PHI) in the course of our representation of our clients, we are required to post notice to clients that their Protected Health Information is subject to electronic disclosure.

Texas law prohibits any electronic disclosure of a client's Protected Health Information to any person without a separate authorization from the client or the client's legally authorized representative for each disclosure. This authorization for disclosure may be made in written or oral form if it is documented in writing by our law firm.

The authorization for electronic disclosure of Protected Health Information described ab ove is not required if the disclosure is made: to another covered entity, as that term is defined by section 181.001 of the Texas Health Code, or to a covered entity, as that term is defined by Section 602.001 of the Texas Insurance Code, for the purpose of: treatment, payment, health care operations, performing an insurance or health maintenance organization function described by Texas Insurance Code Section 602.053; or as otherwise authorized or required by state or federal law. This means that no release is necessary for electronic disclosure to other health care providers, insurance companies, governmental agencies, or attorneys representing adverse parties.

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