Expectant Parent Care Plan Form - Placing baby for Adoption in Texas

Expectant Parent Care Plan

Expectant Parent Name:(Required)

Current Financial Resources

What is your current monthly income?

(please include any benefits)

Will your financial situation change between now and delivery?

Yes

Unsure

Explain if you are unsure:

Does anyone support you financially?

Yes

If yes, who and in what ways?

Are you behind on any bills (i.e., housing, electric, water)?

Yes

If yes, please explain:

Monthly Expenses

Details for Assistance Requested

Assistance requested for RENT?

Yes

How much is your rent monthly?

Reason for need assistance with rent:

I am homeless and need Adoption Choices of Texas to provide financial support for safety and stability during my pregnancy and postpartum recovery.

I am unemployed and need Adoption Choices of Texas to provide financial support for safety and stability during my pregnancy and postpartum recovery.

I have decreased income temporarily and need Adoption Choices of Texas to provide financial support for safety and stability during my pregnancy and postpartum recovery.

Other.

Please explain other:

Any rent balance past due?

Yes

Past due amount? Please provide details:

Assistance requested for ELECTRIC?

Yes

How much is your electric monthly?

Any electric balance past due?

Yes

Past due amount? Please provide details:

Assistance requested for GAS?

Yes

How much is your gas monthly?

Any gas balance past due?

Yes

Past due amount? Please provide details:

Assistance requested for WATER?

Yes

How much is your water monthly?

Any water balance past due?

Yes

Past due amount? Please provide details:

Assistance requested for TRASH?

Yes

How much is your trash monthly?

Any trash balance past due?

Yes

Past due amount? Please provide details:

Reason for need assistance with utilities (electric, gas, water, trash):

I am unemployed and need Adoption Choices of Texas to provide financial support to keep my utilities active during my pregnancy and postpartum recovery, in order to keep my home’s climate safe during extreme weather, allow for refrigeration of medication/food, and meet other basic needs.

I have decreased income temporarily and need Adoption Choices of Texas to keep my utilities active during my pregnancy and postpartum recovery, in order to keep my home’s climate safe during extreme weather, allow for refrigeration of medication/food, and meet other basic needs.

Other.

Please explain other:

Assistance requested for CELL PHONE?

Yes

How much is your cell phone monthly?

Any cell phone balance past due?

Yes

Past due amount? Please provide details:

Reason for need assistance with cell phone:

Other.

Please explain other:

Assistance requested for MEDICAL BILLS?

Yes

Medical amount (prenatal & labor and delivery only):

Any medical bills balance past due?

Yes

Past due amount? Please provide details:

Reason for need assistance with medical bills:

I am uninsured and need Adoption Choices of Texas to provide financial support for pregnancy related expenses to ensure I have the appropriate medical care for myself and the baby, during the pregnancy and postpartum recovery period.

I have private insurance and need Adoption Choices of Texas to provide financial support for pregnancy related expenses that are not covered to ensure I have the appropriate medical care for myself and the baby, during the pregnancy and postpartum recovery period.

Other.

Please explain other:

Other Assistance

Assistance requested for GROCERIES / HYGIENE / TRANSPORTATION:

$20 daily (no children in your care)

$25 daily (children in your care)

Reason or explanation for assistance:

I am unemployed and need Adoption Choices of Texas to provide financial support to keep myself and the baby nourished and healthy during pregnancy and postpartum recovery.

I have decreased income temporarily and need Adoption Choices of Texas to keep myself and the baby nourished and healthy during pregnancy and postpartum recovery.

Other.

Please explain other:

Assistance Requested for CLOTHING:

Yes

Maternity clothing requested (maximum $300):

Do you have maternity clothes available?

Yes

Reason or explanation for assistance:

I am unemployed and need Adoption Choices of Texas to provide financial support for adequate clothing for growing pregnancy belly.

I have decreased income temporarily and need Adoption Choices of Texas to provide financial support for adequate clothing for growing pregnancy belly.

Other.

Please explain other:

Please note the following (check each box to acknowledge):

Physical Health

Are you having any pregnancy-related dental emergencies?

Yes

Emotional Health

Adoption Choices of Texas provides therapeutic counseling with qualified therapists throughout the pregnancy and in post placement services. Adoption Choices of Texas can also send referrals for outside agency care (check box to acknowledge):

I understand

What assistance programs are you part of right now (i.e.-SNAP, WIC, Medicaid, CHIP etc.)?

Monthly amount received from WIC

Monthly amount received from SNAP/Food stamps

Estimated weekly amount spent beyond state benefits

WIC amount:

SNAP/Food stamps amount:

Spending amount:

Would you like the Agency to assist you to find out if you’re eligible for additional community resources?

Yes

If yes, what services are you interested in:

Please note the following (check each box to acknowledge):

Your Adoption Specialist will help you get to and from your pregnancy-related appointments. There may be times when she is not available to take you, but she’ll try to take you as often as she can. The agency can provide alternative transportation including uber, arranging Medicaid transportation to and from doctor appointments, if we are unable to assist.

Your Adoption Specialist is here to provide you emotional support.

Your Adoption Specialist is here to help you get to know your adoptive family, if that’s part of your adoption plan.

In order to provide you the best service possible, your Adoption Specialist needs time to recharge. She is available Monday through Friday during regular business hours, aside from emergencies.

She may schedule a meeting outside of her normal hours, but that does not mean she’s always available.

Please only text or call your Adoption Specialist outside of her normal hours or on the weekend if you are in labor

Your Digital Signature:(Required)

Today's Date(Required)

Check box to acknowledge:(Required)

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