Hospital Plan Questionnaire - Adoption & Beyond | Kansas, Missouri

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Hospital Plan Questionnaire

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone #(Required)

Email(Required)

Address(Required)

Due Date(Required)

MM slash DD slash YYYY

INSURANCE

Group name and number

Insurance #

Do you have Medicaid

Yes

No

Medicaid #

ADOPTION INFORMATION

Name of adoptive family

Phone

Who will notify the couple when you are in labor?

When will they be notified?

PRENATAL CARE/MEDICAL INFORMATION

Doctor's name

Hospital

Have you pre-registered?

Yes

No

Have you taken a hospital tour?

Yes

No

List any complications during your pregnancy

Are you planning to have a C-section?

Yes

No

If yes, what is the date?

MM slash DD slash YYYY

Please list any food allergies

Please list any allergies to medications

Will paternity/DNA testing be done at the time of delivery?

Yes

No

If yes, what company is being used?

LABOR AND DELIVERY

Who is your support person during labor/delivery?

Have you attended a child birth education class?

Yes

No

Have you decided on pain medications during labor and delivery?

Yes

No

If yes, what kinds?

Do you want the adoptive family to be part of the labor and delivery process?

Yes

No

Please indicate what level of involvement the adoptive family will have during labor and delivery:

NOT to come to the hospital at all during labor and delivery

NOT to come to the hospital until ________

In the waiting room during labor and delivery

To visit me in my room during labor but be in the waiting room during delivery

To be in the room during delivery

To cut the baby's umbilical CORD

Untitled

If specifying a time for the adoptive family to join at the hospital, what time?

Who do you want to hold the baby first?

Would you like some private time with the baby immediately after delivery?

Yes

No

Would you like the prospective adoptive mother to receive the second security bracelet? (This may allow the adoptive family to have access to the baby in a different room or see the baby in the nursery without you present.)

Yes

No

FOOTPRINT CARD

Would you like 2 footprint cards made (one for you and one for the family)?

Yes

No

CONTACT WITH THE CHILD AND ADOPTIVE FAMILY

Who will have primary responsibility for caring for the baby?

Myself

Nursing staff

Prospective adoptive family

Please indicate the amount of care you would like to give to the child:

Bottle-feed the baby occasionally

Bottle-feed the baby for EVERY feeding, including night feedings

Breastfeed the baby

Change the baby's diapers

Do you plan to spend time with the baby privately?

Yes

No

Do you want the adoptive family to spend time with you and the baby in your room?

Yes

No

Would you like for them to have a private room where they can visit with the baby privately if space at the hospital is available?

Yes

No

I want the majority of the visits with the family and the baby to take place...

Please indicate the amount of contact you would like with the adoptive family during your stay:

As much as possible... Be there the entire hospital stay.

To visit during the daytime, as much as possible.

To call each day and schedule a time to visit. Stay about __________________ hours per day.

To give me the day of delivery to myself.

To give me the second day in the hospital to myself.

To NOT come to the hospital at all.

Additionally, (be specific)

Please type another option here

If specifying # of hours above, how many?

OTHER VISITORS

Will family and friends be visiting you during your hospital stay?

Yes

No

Will the father of the baby be visiting during your hospital stay?

Yes

No

Special requests for this time at the hospital

Will anyone be EXCLUDED from coming to the hospital?

Yes

No

If yes, who?

IMMUNIZATIONS

Would you like the baby started on the Hepatitis B vaccination?

Yes

No

CIRCUMCISION

What is the sex of the baby?

Boy

Girl

Unknown

If you are having a boy, do you want him circumcised?

Yes

No

Have you discussed this with the prospective adoptive family?

Yes

No

MEMENTOS

Would you like to have professional hospital pictures taken of the baby?

Yes

No

Would you like the hospital to also give an order form for pictures to the prospective adoptive couple?

Yes

No

What items would you like to take from the hospital?

Baby's hat

Bottle

Diapers

Other

Please type another option here

BIRTH CERTIFICATE/CHILD'S NAME

While at the hospital, please complete and turn in the official Birth Certificate form. You will place your information on this form, including the name you have chosen for the child.

What name do you plan to put on the birth certificate?

BABY'S RELEASE FROM THE HOSPITAL/RELINQUISHMENT

Name of your adoption attorney

Phone

You will meet or talk with your attorney during your hospital stay to complete the necessary legal documents for an adoption placement.

When would you like to sign the Relinquishment documents?

As soon as possible after the birth (the soonest you are legally able to sign is 12 hours for Kansas and 48 hours for Missouri)

The second day I'm in the hospital

Any time on the day I'm released from the hospital

I want to the leave the hospital and sign the relinquishment documents at the attorney's/agency's office*

I would like:

To say my goodbyes and leave the hospital before the baby is released.

To be present for the baby's release and leave at the same time as the adoptive family and the baby.

Other

Please type another option here

C-section

If you have to have a C-section and will be in the hospital a couple extra days:

I would like to sign relinquishment documents on the day indicated above and have the baby released from the hospital on the same day I am released.

If the baby could be released earlier, I would like to sign relinquishment documents and have the baby go home with the adoptive family as soon as possible.

OTHER INFORMATION

Who will be bringing the baby's "going home" outfit?

How will you be getting home from the hospital?

I would like to do an Entrustment Ceremony.

Yes

No

When

Where

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