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Mother’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 what intercourse was and the possible consequences?

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

6. Was sex consensual?

7. Was birth control attempted? What kind?

8. Was father told of the pregnancy?

9. What was his reaction?

10. Where did you spend your pregnancy?

11. Who knew about it?

12. Were you educated or prepared for labor and delivery?

13. Who was with you while you were in labor?

14. Were you given an alias in a maternity home or at the hospital?

15. Were you asked about paternity? Did you share this information?

16. What information did you share about your background, heritage, health? To whom did you share it? Was it just you or the father also?

17. Were you given anything to ease pain? What?

18. Did you see your baby in the delivery room?

19. Were you given drugs after delivery?

20. Did you see or hold your baby during the hospital stay?

21. When did you sign relinquishment documents (how soon after delivery?)

22. Did you understand what the documents meant?

23. Were you told about revocation?

24. Did you have your own legal representation?

25. Were you offered support or services after discharge from hospital?

26. Describe how you felt when you were discharged from the hospital.

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

28. After 28 years? 10 years? Now?

29. Who have you shared your story with?

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

31. How did the experience of relinquishment affect the woman you are today?

I am willing to be contacted for clarifying information.

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