"" 1 Your Name Your Last Name Act of Love Alternative Options BIRTH PARENT COUNSELING CONTRACT FOR SERVICES Your counselor will assist you in completing your paperwork, coordinating your contact with the adoptive famil y prior to and after delivery, and guiding you through the placement process. They can also provide brief therapy and support as desired. State regulations require that we have at least two face-to-face counseling sessions with you prior to relinquishment, unless you refuse such counseling. Please indicate the support you would like from your counselor: Counseling concerning alternatives for keeping and raising my childCounseling concerning the placement decision Mediation between me and the birth fatherCounseling with my family to gain their support Parenting Skills Birth Control InformationMoney-Management Counseling for abuse/trauma issues Referral for Medication OtherNo counseling; I specifically waive my right to counseling If Otherspecifyno-icon Your counselor plans to meet with you, in person or by phone. Please consider what help you may need before the placement as well as after, and indicate what use of this time will be most helpful to you. Before placement, I would like to meet with my counselor: Select An OptionOnce a week Every two weeks Only if I call Just to complete paperwork and line up family Your counselor will work out meeting times and places with you in your first meeting. If, at any time, you need to speak to your counselor, she/he can be reached by calling the birth parent line at (800) 835-6360. They will have your counselor call you as soon as possible. Birth Parent Signatureno-icon Dateof signaturedate_range NEXT Previous Next
