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Father’s Volunteer Form

Name (optional) or assigned sequence number

Email Phone

1. Year of relinquishment

2. Age at relinquishment

3. State

4. Did you understand that pregnancy could result from your sexual activity?

5. Were you drunk or under the influence of drugs?

6. Did your partner verbally consent to intercourse?

7. Was birth control attempted? What kind?

8. How soon were you told of the pregnancy?

9. Were you sure you were the father?

10. Who did you tell?

11. What options did you discuss?

12. What did you want to do about it?

13. Who knew about it?

14. What actions did you take?

15. Did you continue the relationship?

16. Did you provide emotional support?

17. Did you provide financial support?

18. Did you see the mother during the pregnancy?

19. Did you participate in the birth or delivery process?

20. Where you asked about paternity? Who asked? What information did you share (background, heritage, health)?

21. Did you see or hold your baby?

22. Did you sign any documents? What?

23. Describe how you felt when you knew the relinquishment was signed

24. Did the relinquishment change your attitudes or behaviors about sex and relationships?

25. Did your feelings about the mother change after relinquishment?

26. How would you describe your feelings and behaviors a year after relinquishment?

27. After 5 years? 10 years? Now?

28. Who have you shared your story with?

29. Have you sought help or support from a therapist or support group?

30. How did the experience of relinquishment affect the man you are today?

I am willing to be contacted for clarifying information.

Your reponses will be emailed to the address you've provided.