Birth Parent Statements of Understanding 1. Right to Parent* As the birth parent of my child, I have the primary right to parent my child if I so choose, even if I am a minor. I will make sure that it is my wish to place my child for adoption before I begin working with Heart to Heart Adoptions. 2. Fraud* I understand that misrepresenting my pregnancy or my desire to place for adoption is considered fraud. I also understand that receiving assistance and support from two different adoption agencies at the same time also may be considered fraud. Heart to Heart Adoptions, Inc. may choose to prosecute me if I have committed a fraudulent act. I also understand that adoption agencies may share information about me with other agencies in an effort to prevent fraud. 3. Counseling* I understand that Heart to Heart Adoptions, Inc. will provide me with counseling and support to help me in making decisions concerning my pregnancy. A licensed social worker will be assigned as my counselor to assist and support me through the adoption process. 4. Living Expenses* I understand that Heart to Heart Adoptions, Inc. may assist me with current living expenses during my pregnancy including rent, food and utility payments if allowable in the state of services. Heart to Heart Adoptions, Inc. will also assist me in accessing any local resources that may be available to me during my pregnancy or following the delivery of my child. I understand the agency is limited by law regarding the assistance offered. I understand Heart to Heart Adoptions, Inc. is unable to pay for past bills or deposits. 5. Medical Expenses* If I do not currently have medical coverage, Heart to Heart Adoptions, Inc. will assist me in securing medical coverage for my pregnancy. This may include applying for Utah Medicaid if applicable and I agree to work cooperatively with them to do so. 6. Irrevocable Relinquishment* If I decide on an adoption plan for my child, I will sign the relinquishment papers. I understand that, based on the laws in Utah, I must wait at least 24 hours following the delivery of my child to sign the relinquishment papers. I realize that when I sign those documents, all my rights and responsibilities to this child will be ended and that my consent to adoption will be final, irrevocable and legally binding. Laws from other states may be different. 7. Adoptive Placement* Heart to Heart Adoptions, Inc. will assist me in selecting the adoptive parents who match my request, though they cannot guarantee all my preferences will be met. All adoptive parents have been thoroughly screened by Heart to Heart Adoptions, Inc. and found appropriate for placement.I understand I have the option to choose the adoptive parents. If I forgo this choice, Heart to Heart Adoptions, Inc. will choose the adoptive parents they feel most appropriate to adopt my child. 8. Selection and Information Sharing* If I place my child with Heart to Heart Adoptions, Inc, I may be involved in the selection of an adoptive family. I understand that non-identifying information about the other birth parent, the pregnancy, and I will be shared with any family I may be considering as potential parents for my child. I have or will sign a release of information, allowing information specifically for this purpose. 9. Privacy* I understand that Heart to Heart Adoptions, Inc. will not disclose my address, phone number or certain other identifying information to the adoptive family without my permission, but that they cannot guarantee privacy in any adoption. 10. Contact with Adoptive Parents* I understand that the agency will make every attempt to assure that any agreement for contact and exchange of information between the adoptive parents of my child and myself will be upheld, but that they cannot guarantee any arrangements. A contract agreement will be entered into and signed by the adoptive parents and myself before placement. Unless otherwise arranged, contact will be facilitated through the agency. 11. Religion* I understand and agree that Heart to Heart Adoptions, Inc is placing my child with a family that may or may not practice religion as I do and that the adoptive parents may raise my child in the faith of their choice. I understand that Heart to Heart Adoptions, Inc works with families of all faiths and will attempt to place my child with a family who has beliefs similar to mine, if that is my wish. 12. Promises* I wish to state that there have been no promises made to me that would influence my decision to place my baby for adoption. I have not been offered gifts or promises for placing my child for adoption. I understand that gifts or allowances beyond the guidelines set by Heart to Heart Adoptions, Inc. cannot be given. 13. Utah Mutual Registry* I understand that if I place my child in Utah, that the Utah Mutual Consent Registry makes it possible for the birth parents and adoptee to be reunited when the adoptee is 18 years of age. I understand that contact will be possible through this resource only if both adoptee and birth parent register. Other states may have similar registries. 14. Liability* I acknowledge that Heart to Heart Adoptions is providing services to me in good faith and I do not hold them responsible or liable in any way for any harm or accident that may come to me during my association with them. 15. Application for Services* I, at my own discretion, have decided to apply with Heart to Heart Adoptions, Inc. for assistance with my adoption plans. All information I have supplied throughout the application process is true and correct to the best of my knowledge. 16. Varied Services* I also understand that services are rendered on a case-by-case basis and that services provided to another birthmother may not be the same as those provided to me. 17. Alcohol and Drug Use* I understand that the use of alcohol or illegal drugs during my time as a client with Heart to Heart Adoptions, Inc. is not allowed. If I am using drugs or alcohol while a client through this agency, they have the option of terminating services and or refer me to a drug or alcohol treatment facility. 18. Drug Testing* I understand that Heart to Heart Adoptions, Inc. will request that I participate in drug testing. 19. Policies and Procedures* I understand that there are Policies & Procedures of Heart to Heart Adoptions, Inc. that I must follow. If I decide not to follow these policies I understand that Heart to Heart Adoptions, Inc. has the right and responsibility to discontinue their services. Before accepting any services from Heart to Heart Adoptions, I agree to follow those Policies and Procedures. 20. Permissions* I give permission for my case and social workers to discuss my case with staff members of the agency, health workers, other adoption agencies and law enforcement officers. 21. Services Provided By* I understand that staff members of Heart to Heart Adoptions who are providing me services may also be providing services to the adoptive family. I also understand that such an arrangement might create a conflict of interest between my concerns and the concerns of the adoptive family. I know I have the right to request separate staff members than those working with adoptive families if I feel a conflict may arise. 22. Birthfather Rights* I understand that according to the adoption laws of the state of Utah that the birth father may have the option of parenting the child if he is known and paternity has been established. In order to establish paternity in Utah he must support me emotionally and financially during my pregnancy or he must file with Utah Vital Records on the State Paternity Registry. Paternity laws of the father’s state of residence must also be complied with. Furthermore, I understand if the birthfather resides in another state or I am withholding information about my whereabouts, I may be putting an adoptive placement in jeopardy. Also, if I am married, my legal husband must consent to an adoption even if he is not the child’s biological father. Notice must also be given to any birthfather I may identify on the birth certificate. 23. Release of Information* I understand that in signing the "Release of Information" form that I am authorizing all psychological, psychiatric and health information or birth certificate records pertaining to me or any child of mine to be released to Heart to Heart Adoptions, Inc. 24. Choice to Travel* If I chose to travel to Utah, I wish it to be known that I have willingly and knowingly chosen to leave the state in which I have been living (listed below). I take full responsibility for my decision to travel and for any consequences, physically and emotionally for that decision. I also take full responsibility for any of my children that may be traveling with me. The state I'm leaving to travel to UtahAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasVermontVirginiaWashingtonWest VirginiaWisconsinWyoming25. Jurisdiction* If I chose to travel to Utah, I wish it to be known that I expressly submit to the jurisdiction of the courts of the state of Utah and to be bound by laws of Utah. 26. Legal Advice* I understand that I have the legal right to consult with an attorney of my own choice and to seek independent legal counsel prior to make the decision to place my child for adoption. Your Email Address* Email PreferencesWe understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.No. Please DO NOT email me a confirmation.Yes. Please send an email confirmation for my records.Birth Mother SignatureI, the undersigned, declare that I am not under the influence of any drugs, alcohol or medication that may influence my reasoning or judgment and sign this document by my own free will and choice.Date Signed* Type Your Name* First Last Signature*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.