Agency Agreement

hereinafter referred to as “Expectant/Birth Parent”. Agency, acting as agent for the adoptive parents, agrees to provide Expectant/Birth Parent with the following care and services: counseling, agreed necessary living expenses, confidentiality, protection of records, and legal fees. Do you understand?(Required)


Care and services provided by Agency, acting as agent for the adoptive parents, may include: a) counseling sessions; b) approved qualified living costs; c) legal fees related to the adoption proceeding; d) case management; and e) birthing support. Do you understand?(Required)


Expectant/Birth Parent hereby agrees to permit Agency, as agent for the adoptive parents, sole and exclusive right to place his/her child(ren) for adoption. This requires the cooperation of Expectant/Birth Parent with Agency’s policies, including (Please check each acknowledging your understanding):(Required)
Should Expectant/Birth Parent make the decision to parent the child, he/she agrees that Agency, acting as agent for the adoptive parents, will cease payment of any and all expenses on behalf of Expectant/Birth Parent and/or the child. The expenses shall include, but are not be limited to, Expectant/Birth Parent’s living expenses; attorney fees for agency, adoptive parents, and Expectant/Birth Parents; as well as any fees paid to any Case Manager, Counselor, or Doula working with Expectant/Birth Parent. Should Expectant/Birth Parent make the decision to parent the child, or work with another agency or law firm, this Agreement is terminated. Expectant/Birth Parent understands and acknowledges that if the pregnancy is terminated by miscarriage or medical necessity, or if the child is stillborn at birth, Agency, acting as agent for the adoptive parents, will no longer be responsible for any of Expectant/Birth Parent’s expenses as listed above, and this Agreement shall be terminated. Do you understand?(Required)


Expectant/Birth Parent understands and acknowledges that it is his/her responsibility to apply for Medicaid coverage, and to give Medicaid the correct information in a timely fashion to process his/her application and acquire Medicaid coverage. If Expectant/Birth Parent has told Agency he/she is covered by Medicaid or private insurance, or if Expectant/Birth Parent should qualify for Medicaid coverage but does not cooperate with Medicaid to have coverage put into effect or otherwise fails to obtain coverage that he/she is qualified for, he/she understands and acknowledges that he/she will be responsible for any medical bills that should have been covered by Medicaid, and that Agency/Adoptive Parents will not pay those bills. Do you understand:(Required)


I fully understand that the decision to relinquish my child is a decision only I can make. This decision will be made without coercion, influence, or inducement from anyone. I have voluntarily decided to work with Agency, acting as agent for the adoptive parents, during my pregnancy, because it is my intention at this time to make an adoption plan. If at any time I change my mind about proceeding with adoption planning, I will immediately notify Agency, acting as agent for the adoptive parents, of the change in plans. I agree to allow Agency to take a picture of me, which may be shown to prospective adoptive parents prior to matching me with a family, and which may be given to authorities if any criminal activity occurs while I am working with Agency. I understand that the identifying information and any other pictures I have provided to Agency, as well as all medical information and/or other information in my file will also be given to the adoptive parents unless I specifically state otherwise in writing. I agree to allow agency to use various types of programs and online information systems to gather information for my file. These includes but are not limited to the following: Microsoft Exchange Server, Drop Box, Slack, ASANA, Microsoft 365, Google Drive, Teams, Zoom, Citrix WebEx,& Sharefile. I hereby give permission for the agency to save my adoption file on these drives, systems, platforms, and apps knowing that they could be compromised by hackers. Agency will use best efforts to keep information confidential regarding the adoption, health history disclosed to us and all personal shared information. I understand that after placement of the child, if I suffer from any ongoing health conditions and/or concerns, I should notify Agency so that the adoptive parents can be notified. In the event of my death, Agency will notify the adoptive parents and inform them of the cause of my death. I fully understand that Agency, acting as agent for the adoptive parents, is not a charitable or welfare organization established to provide free care for expectant mothers who are planning to parent their child after delivery. I hereby understand that I may hire my own attorney to represent me in this adoption plan. I understand and acknowledge that Jennifer Womack is the attorney for Agency and does not and will not represent me.


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