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If you are interested in learning more about our facilitation services, please complete and submit the following online request form. Before completing review the previous section on "Next Steps & Fees". As a potential client of A Loving Alternative Adoption Service, you may specific what traits or characteristics you are open to.

General Information

Based upon what you currently understand about our facilitation services, where are you in your decision process:

I am very interested in becoming one of your select clients. Please contact me as soon as possible.
I am leaning toward using your services, however, I still have some questions and would like to speak with someone personally.
I am uncertain about using a service such as yours, but I would like to speak with someone personally.

Are you currently trying to adopt?
Yes No

If yes, how long have you been waiting?

If you are not currently trying to adopt, when are you planning to begin?
Are you working with an adoption attorney?
Yes No

If yes, please provide us with your attorney's name in the box below:

Are you working with an adoption agency?
Yes No

If yes, please provide us with the agency's name in the box below:

Have you completed an adoption home study?
Yes No In progress

Have you created a "Dear Birth Mother" letter or profile?
Yes No In progress

Traits & Characteristics Desired (this section is optional)

What is the maximum child's age you would consider?

Do you have a preference about the sex of the child?
Boy Girl Either

Are you open to twins or possible multiple birth situation?
Yes No Maybe

Are you open to a situation where the birth father is unknown or
a one-night stand?
Yes No Maybe

Are you open to meeting the birth parents prior to the birth?
Yes No Maybe

Are you comfortable sending pictures, letters and updates yearly after the birth?
Yes No Maybe

Are you open to meeting the birth parents after the birth?
Yes No Maybe

Would you be ready to accept a situation where the baby is due immediately
or already at the hospital?
Yes No Maybe

Are you open to a situation where the birth mother drank or did drugs?
Yes No Maybe

Are you open to a situation where there is a high risk of either physical
or mental disabilities?
Yes No Maybe
Are you open to a child that is all or part: (Please check all that apply.)
Caucasian
100%
50%
25%
Hispanic
100%
50%
25%
African American
100%
50%
25%
Asian
100%
50%
25%

Please list any other concerns important to you that are not listed above.
Feel free to be as specific as you feel necessary.

Information About You:
Marital Status:
Wife's Age:
 		Husband's Age:
Wife's Race/Etnicity:
 Husband's Race/Etnicity:
Wife's Religion:
 Husband's Religion:
Number of Children at Home:

Will your kid(s) be raised by a stay-at-home parent?
Yes No


Your Contact Information:
Please contact us via:
Name(s):
Street Address:
City:
State:
Country:
Zip/Postal Code:
Phone:
Best time to call:
AM PM
Email:

 
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