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Are you asking 1) if it is possible to have such a document or 2) if there is a document like that available free somewhere online?
I ran a quick search and was unable to find one that even came close to what would be required. In addition, the person can withdraw from the agreement at any time prior ro the adoption under a "public policy exception".
I've seen a number of those drafted over the years and many of us disagree with what has to be in them. In my opinion, you need to be sure that the document not only advises them of their right, including the right to withdraw, but also advises them to go and have the document examined by their own attorney and has a place for them to sign saying that they had the opportunity to have it examined.
This is the kind of form that is rarely used and so it's not likely you're going to find one online. Although I'd recommend having your own attorney draft one from scratch for you with your unique facts, you may be able to have LegalZoom do one (they don't have one right now that I can see). The problem is that it will be generic.
Please ask any additional questions that you have in this thread. I want to be sure that all of your questions are answered.