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Anonymous Poll

Are you considering adoption?

	Yes
	No

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Potential Birth Mums Questionnaire

Are you pregnant and considering making an adoption plan? Do you think it would be helpful to talk with someone who has been through it all before? If so, please fill out the brief form below. We will soon match you with a mentor, another member of “Birth Mum’s Supporting Birth Mums” who has already placed a child for adoption and has volunteered her time to help ease your journey. She will be there to listen as you consider this choice.

Mandatory *

Name :	Field not valid (required or bad value)
Your Age :	Field not valid (required or bad value)
Your Due Date :	Field not valid (required or bad value)
Email Address * :	Field not valid (required or bad value)
Your Address :
Field not valid (required or bad value)
What best describes you? :	Field not valid (required or bad value)
Have you made contact with Child Youth and Family- Adoption Services yet? :	Yes No Field not valid (required or bad value)
Have you chosen a family yet? :	Yes No Field not valid (required or bad value)
What type of adoption are you leaning toward? :	Open Closed Field not valid (required or bad value)
Any other comments or information you would like to tell us – (is the birth father involved, do you have other children, etc): :
Field not valid (required or bad value)
How can we best support you? :
Field not valid (required or bad value)
Where did you hear about us? :	Field not valid (required or bad value)