Agreement Between Agency and Expectant Mother

This Agreement is between Adoption Choices of Colorado, a licensed adoption agency, hereinafter called "Agency," and (enter your name below), hereinafter called "Expectant Mother."(Required)

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The Agency agrees to provide Expectant Mother with the following care and services at no charge to her: relinquishment counseling; court-awarded necessary pregnancy-related living expenses; confidentiality; protection of records; and legal fees (for placement only).

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COVERED COSTS: Care and services provided by Agency, to Expectant Mother, may include: (a) relinquishment counseling sessions and additional counseling related to the relinquishment/placement by Agency’s counselor as requested by Expectant Mother; (b) pregnancy-related living expenses; (c) legal fees related to the relinquishment and adoption proceedings (non-contested); and (d) caseworker/social worker assistance.

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COSTS NOT COVERED: Expectant Mother understands that Agency cannot provide the following services of the following expenses free of charge to the Expectant Mother: (a) counseling sessions with a provider other than Agency’s counselor; (b) expenses not related to the pregnancy; and (c) any item prohibited by state or federal law.

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EXPECTANT MOTHER RESPONSIBILITIES: Expectant Mother hereby agrees to permit Agency sole and exclusive right to place her child for adoption.

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EXPECTANT MOTHER RESPONSIBILITIES: Expectant Mother understands and acknowledges that if the pregnancy is terminated by miscarriage or medical necessity, or if the child is stillborn at birth, Agency will no longer be responsible for any of Expectant Mother’s expenses as listed above, and this Agreement shall be terminated.

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EXPECTANT MOTHER RESPONSIBILITIES: Further, if the Expectant Mother is not on Medicaid or private insurance and the prospective adoptive parent(s) agree to pay for medical bills incurred during the pregnancy, the Expectant Mother has the responsibility of forwarding all medical bills to Agency for payment. Expectant Mother agrees that if the Expectant Mother fails to forward these bills within one (1) year, neither the Agency nor the adoptive parent(s) have a legal obligation to pay the delinquent medical bills. Expectant Mother is entitled to receive proof of payment of said medical bills upon asking Agency for a receipt or letter.

Expectant Mother's Statement

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I fully understand that the decision to relinquish my child is a decision only I can make. This decision is to be made without coercion, influence, or inducement from anyone. I have voluntarily decided to work with Agency, acting as agent for the adoptive parent(s), during my pregnancy because it is my intention at this time to make adoption plans. If at any time I change my mind about proceeding with the adoption planning, I will immediately notify Agency of the change in plans.

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I acknowledge that the prospective adoptive parent(s) and the Agency’s staff, attorneys, employees, independent contractors, and other parties will rely on information I have provided to decide to proceed with the prospective adoption, and the Court will rely on this information during the adoption related proceedings. In my written and verbal communication in connection with the adoption, I have not provided any false or misleading information of any kind. The Agency has stressed to me the importance of providing full and accurate information in an adoption, particularly as it relates to the biological father, or any way to contact him with regard to this adoption.

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I hereby waive any claim of privilege and agree that the information provided by my counselors, physicians, and myself may be given to the prospective adoptive parent(s), their agency, their attorney, other attorneys, and other state officials, including law enforcement authorities, through all forms of communication.

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I understand that the written, identifying information I have provided to Agency will be given to the prospective adoptive parent(s) unless I specifically state otherwise in writing.

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I acknowledge that I can obtain a copy of all documents that I have signed with the Agency relating to my adoption plan by asking in writing to receive such documents.

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I fully understand that Agency 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 further understand that Virginia L. Frank, works on behalf of the prospective adoptive parent(s) on this potential adoption. I understand that I will have my own attorney who will be present at my consent hearing or who will be available to me for legal counsel should I decide to request that the Court accept my relinquishment and consent without requiring a personal appearance at the Court. I understand that the attorney representing me is independent of the Agency.

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In my written and verbal communications in connection with my adoption plan, I have not provided any false or misleading information of any kind, including, but not limited to, information concerning myself, the biological father or the background or medical history of my family. If Agency deems it necessary, I agree that Agency can run a criminal background check on me. I further understand and agree that I will submit to random drug testing if Agency or prospective adoptive parent(s) request such tests.

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I understand that if I have been fraudulent, I agree to assume full responsibility for paying all costs incurred by Agency on behalf of myself and/or the child. These expenses shall include but may not be limited to: (a) any living expenses paid; (b) attorney fees; and (c) caseworker fees. Further, I understand that failure to pay all costs incurred by Agency as discussed in this paragraph, may result in my account being turned over to a collection agency. Should I make the decision to parent the child or to work with another agency or law firm, this Agreement is terminated.

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I understand that any agreement, written or unwritten, entered with the adoptive parent(s) regarding future communication/contact between myself, the adoptive parent(s), and the child, are contractual in nature. I understand that if I enter a signed Post Adoption Contact Agreement (PACA) with the adoptive parent(s), it may be enforced by the Court. I further understand that entering an informal or formal agreement (PACA) for post adoption contact will not revoke my relinquishment or ever be grounds to undo the adoption. The Agency cannot and will not mediate, arbitrate, or otherwise enforce any agreements between me and the adoptive parent(s).

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I further understand that accepting financial assistance from more than one adoption agency and/or adoptive family simultaneously, or if I accept financial assistance but am not actually pregnant or do not actually intend to complete an adoption plan, may be considered fraud, and could result in criminal or civil prosecution.

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Under penalty of perjury, I declare that I have read and understand the foregoing, that I have had the opportunity to ask any questions I may have which have been answered to my satisfaction. I agree to abide by this Agreement fully and completely. All the information which I have provided, both verbally and in writing, to Adoption Choices of Colorado, is true and correct to the best of my knowledge.

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By submitting this form, you consent to the transmission of your information over the internet and understand the associated risks.

Adoption Choices of Colorado is a full service adoption agency providing unplanned pregnancy counseling & adoptive family assistance.

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Agreement Between Agency and Expectant Mother