1 (Proposed) CONTACT
PREFERENCE FORM FOR BIRTH PARENTS
(example - not drawn to scale)
The Texas Department of State Health Services - Central Adoption Registry needs the following information to find and match your request with your records. (Please print legibly)
Name of child on original birth record: ______________________________________________
Date of birth: ___________________________________ Sex: Female Male
Hospital Name: ________________________________________________________________
County: ____________________________ City: ____________________________________
Mother’s name (as shown on birth certificate): ________________________________________
Adoption agency involved with adoption (if known): ___________________________________
______________________________________________________________________________
IF THE ORIGINAL BIRTH CERTIFICATE IS RELEASED, WHAT IS YOUR
PREFERENCE ABOUT CONTACT WITH THE ADOPTEE?
The Texas Department of State Health Services - Central Adoption Registry cannot accept this Contact Preference Form unless it is fully completed.
I am the: birth mother birth father Today’s Date: _______________________
Please check one of the three boxes and provide the required information.
I would like to be contacted. My current name: ___________________________________
Address: ______________________________________________________________________
Telephone: ____________________________________________________________________
I would prefer to be contacted only through an intermediary.
I prefer not to be contacted at this time. If I decide later that I would like to be contacted, I will register with the Texas Central Adoption Registry.* I have completed a Birth Parent Updated Medical History form (Form BVS 246R) and have filed it with the Texas Central Adoption Registry. Attached is a Certificate (Form BVS 247R) from the Texas Central Adoption Registry verifying receipt of the Birth Parent Updated Medical History form. IF NO CONTACT IS YOUR PREFERENCE YOU MUST:
1. Request and complete a Birth Parent Updated Medical History form from the Central Adoption Registry.* (Form BVS 246R)
2. Request from the Central Adoption Registry a Certificate of Receipt of Birth Parent Updated Medical History form (Form BVS 247R) and attach it to the completed Contact Preference Form and submit it to the Texas Department of State Health Services - Central Adoption Registry.
For additional information or forms, please contact the adoption agency involved with the adoption or the Central Adoption Registry:
Central Adoption
Registry
(Address and phone number of Registry will go here.
This is only a proposed form and not a form in use yet.)
*Voluntary adoption
registries may be maintained by the adoption agency involved with your
child’s adoption. Contact those agencies directly or contact the Central
Adoption Registry
maintained by the Texas Department of State Health Services.
Form BVS 247R