Intended Parent Questionnaire

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  • 1. F amily S ource C onsultants, LLC “Bringing Dreams & Miracles Together” Intended Parent Questionnaire Please include photos of yourself/family with this questionnaire. We encourage you to provide accurate and thorough responses so that we can match you appropriately with a Surrogate. Use your TAB key to navigate through this form. General Information Date:       Partner #1 first initial:       Partner #2 first initial:       Marital Status: Married How long have you been married?       How long have you been in a committed relationship?       Do you have children? Yes No If yes, what are their genders and ages?       Do you have legal and physical custody of the fore mentioned children? Yes No Please explain:       If yes, did you carry the baby (ies) yourself, adopt, or have the child(ren) via Surrogacy and/or Egg Donation?       What state do you live in?       Closest major airport:       Describe area in which you live (suburban, rural, urban, etc.):       Please describe your home and neighborhood:       How long have you lived at this location?       Previous location:       Please describe your home life:       What are your childcare plans for the child/ren to result from this surrogacy?       Name and location of fertility clinic:       Will you need an Egg Donor? Yes No Sperm Donor? Yes No Physical/Personal Information Family Source Consultants, LLC Intended Parent Application 1
  • 2. Partner #1 Age:       Birth date:       Height:       Weight:       Eye color: brown green hazel blue other       Hair color (natural):       Race(s):       Ethnic background(s):       Religious affiliation:       If you have ever lived in another country, where?       When? From:       To:       What languages do you speak/write?       Current occupation/position:       Previous occupation/position:       Date and location (city and state) of high school graduation:       Did you attend college/university? Yes No If yes, where? Name(s) and location(s) of college(s)/university (ies): School name:       What were the years you attended?       to       Date of Graduation:       School name:       What were the years you attended?       to       Date of Graduation:       School name:       What were the years you attended?       to       Date of Graduation:       Please list any degree(s) that you hold:       Other licenses/certificates/areas of training, etc.:       Have you ever been, or are you currently in the military? Yes No If yes, please specify and list dates:       Have you ever been hospitalized or had a major illness? Yes No If yes, please explain:       Family Source Consultants, LLC Intended Parent Application 2
  • 3. Have you ever had surgery (minor or major)? Yes No If yes, please explain:       Do you have any chronic medical conditions/problems? Yes No If yes, please explain:       Partner #2 Age:       Birth date:       Height:       Weight:       Eye color: brown green hazel blue other       Hair color (natural):       Race(s):       Ethnic background(s):       Religious affiliation:       If you have ever lived in another country, where?       When? From:       To:       What languages do you speak/write?       Current occupation/position:       Previous occupation/position:       Date and location (city and state) of high school graduation:       Did you attend college/university? Yes No If yes, where? Name(s) and location(s) of college(s)/university (ies): School name:       What were the years you attended?       to       Date of Graduation:       School name:       What were the years you attended?       to       Date of Graduation:       School name:       What were the years you attended?       to       Date of Graduation:       Please list any degree(s) that you hold:       Other licenses/certificates/areas of training, etc.:       Family Source Consultants, LLC Intended Parent Application 3
  • 4. Have you ever been, or are you currently in the military? Yes No If yes, please specify and list dates:       Have you ever been hospitalized or had a major illness? Yes No If yes, please explain:       Have you ever had surgery (minor or major)? Yes No If yes, please explain:       Do you have any chronic medical conditions/problems? Yes No If yes, please explain:       Background Information Partner #1 Where were you born?       How many siblings do you have?       Are you the: youngest middle oldest only child? Is your mother still living? Yes No Father: Yes No Are all your siblings still living? Yes No If not, what was their age(s) when they passed away?       Do you have a criminal record of any kind? Yes No If yes, please explain:       Have you ever been convicted of a felony? Yes No If yes, please explain:       Have you ever been denied acceptance into an adoption, surrogacy or egg donation program? Yes No If yes, please explain:       Have you ever been tested for HIV/AIDS? Yes No If yes, please list all dates and results:       Family Source Consultants, LLC Intended Parent Application 4
  • 5. Have you ever suffered from severe depression? Yes No If yes, please list dates and explain:       Have you ever been to see a psychiatrist, psychologist, or any other mental health professional? Yes No If yes, please list dates and explain:       Have you ever been prescribed psychiatric medication(s)? Yes No If yes, please list dates and explain:       Have you ever been hospitalized due to a psychiatric issue? Yes No If yes, please list dates and explain:       Do you drink alcohol? Yes No If yes, how often: Daily Do you smoke cigarettes? Yes No If yes, how often:       Do you use any illegal drugs, including marijuana? Yes No If yes, please specify:       Have you used illegal drugs in the past? Yes No If yes, please specify:       Partner #2 Where were you born?       How many siblings do you have?       Are you the: youngest middle oldest only child? Is your mother still living? Yes No Father: Yes No Are all your siblings still living? Yes No If not, what was their age(s) when they passed away?       Do you have a criminal record of any kind? Yes No If yes, please explain:       Have you ever been convicted of a felony? Yes No If yes, please explain:       Family Source Consultants, LLC Intended Parent Application 5
  • 6. Have you ever been denied acceptance into an adoption, surrogacy or egg donation program? Yes No If yes, please explain:       Have you ever been tested for HIV/AIDS? Yes No If yes, please list all dates and results:       Have you ever suffered from severe depression? Yes No If yes, please list dates and explain:       Have you ever been to see a psychiatrist, psychologist, or any other mental health professional? Yes No If yes, please list dates and explain:       Have you ever been prescribed psychiatric medication(s)? Yes No If yes, please list dates and explain:       Have you ever been hospitalized due to a psychiatric issue? Yes No If yes, please list dates and explain:       Do you drink alcohol? Yes No If yes, how often: Daily       Do you smoke cigarettes? Yes No If yes, how often:       Do you use any illegal drugs, including marijuana? Yes No If yes, please specify:       Have you used illegal drugs in the past? Yes No If yes, please specify:       Personality Partner #1 Please describe your personality in as much detail as possible. What are your positive and negative qualities? values and beliefs? :       What are your interests and hobbies? Family Source Consultants, LLC Intended Parent Application 6
  • 7.       Please describe your spouse/partner in as much details as possible. Tell us about his/her personality including positive and negative traits. What is/are your favorite characteristics about him/her?       What kind of parent do you think your spouse/partner will be? Or, if he/she has children already, what kind of parent is your spouse/partner?       Partner #2 Please describe your personality in as much detail as possible. What are your positive and negative qualities? values and beliefs? :       What are your interests and hobbies?       Please describe your spouse/partner in as much details as possible. Tell us about his/her personality including positive and negative traits. What is/are your favorite characteristics about him/her?       What kind of parent do you think your spouse/partner will be? Or, if he/she has children already, what kind of parent is your spouse/partner?       Fertility/Pregnancy History (If not applicable, please skip this section) How long have you been going through infertility?       Have you ever become pregnant with the assistance of an infertility clinic/reproductive Family Source Consultants, LLC Intended Parent Application 7
  • 8. endocrinologist? Yes No If yes, please list date(s) and explain:       Have you ever had a miscarriage? Yes No If yes, when?       How far along were you in the pregnancy (ies)?       Have you ever had a stillborn baby? Yes No If yes, when?       How far along were you in the pregnancy?       Please discuss anything you would like Family Source (and your potential Gestational Surrogate) to know about any fore mentioned pregnancy experiences.       Surrogacy Specific Questions (Both Intended Parents) If this is your first time going through surrogacy, how long have you been considering this route to parenthood?       Please describe when/how the idea to pursue surrogacy to build your family came to mind:       How many attempts with a Surrogate will you be willing to try to conceive a child?       Please explain:       If surrogacy does not lead to the birth of a child/ren for you, what would be your next step(s)? (Adoption, etc?)       Have you discussed your plans to become parents via surrogacy with any of your family or friends? Yes No Family Source Consultants, LLC Intended Parent Application 8
  • 9. If yes, what were the reactions/responses?       If you are already parents via surrogacy, please tell us about this experience in as much detail as possible and include dates of pregnancy (ies) and delivery (ies):       If you are already parents via surrogacy, what was your relationship like with your former Gestational Surrogate throughout the pregnancy?       Please explain the current relationship you have with your former Surrogate:       Please discuss the qualities you believe to be most important in a Gestational Surrogate:       Please describe your “ideal” Gestational Surrogate:       Are there any circumstances which would cause you to NOT want to work with a potential Surrogate? Yes No If yes, please explain:       Will you tell your child who results from this surrogacy about the way in which he/she was brought into the world? Yes No If yes, at what age do you envision sharing this information?       Please explain:       How do you think you will feel, on an emotional level, having a Surrogate carry your baby/ies? Please address any concerns you have regarding this matter.       How much contact would you like with your Gestational Surrogate throughout the pregnancy? Do you hope to receive updates from her in between doctor appointments via telephone and/or Family Source Consultants, LLC Intended Parent Application 9
  • 10. email? Would you like her to occasionally send/email you pictures of herself and share details about the pregnancy? (Please be specific in describing what you have in mind, as we want to make sure you are matched accordingly.)       How much contact do you envision having with your Gestational Surrogate after the pregnancy and delivery? (Please be specific in describing what you have in mind, as we want to make sure you are matched accordingly.)       Are you interested in attending doctor appointments/ultrasound appointments with your Gestational Surrogate? (Both reproductive endocrinologist and OB) Yes No Please explain:       Do you plan on filming or taking pictures of your Surrogate throughout this process? Yes No Please explain:       Would you like to be in the delivery room when your baby (or babies) is/are born? Yes No Please explain:       If yes, would you like to film or take pictures during the delivery? Yes No Please explain:       Please write a short note to your future Gestational Surrogate:       The following questions are ones that you and your future Surrogate must agree upon. It is most crucial that you answer these questions with all honesty, as it is pertinent in making sure you are matched appropriately. Oftentimes, the reproductive endocrinologist will transfer 2-4 embryos in order to increase the likelihood that a pregnancy will occur. Because of this, it is possible that your Surrogate could Family Source Consultants, LLC Intended Parent Application 10
  • 11. become pregnant with multiples (two or more babies). How would you feel about becoming parents to twins?       How would you feel about becoming parents to triplets?       If it is confirmed that your Surrogate is carrying triplets or more, would you opt to selectively reduce (of course, taking your doctor’s advice into consideration): Yes No Please explain:       What if it is confirmed that the baby has a very serious medical condition -would you choose the option of early termination? (Keep in mind, this determination would likely be made sometime around 12-16+ weeks) Yes No Please explain:       If it is determined that the baby has Down’s syndrome, would you choose to terminate the pregnancy? Yes No Please explain:       Do you think you may want (or that your doctor may advise) your Surrogate to have an amniocentesis? Yes No Please explain:       Please discuss any additional information that you would like your potential Gestational Surrogate to know about you:       Please read the below statements and sign/date stating that you agree: By entering my/our name(s) below, I /we agree that the information provided in this questionnaire is accurate and true to the best of my/our knowledge. Family Source Consultants, LLC Intended Parent Application 11
  • 12.             Partner #1 Date             Partner #2 Date Please email, mail or fax your completed application to our office for review. FSC will be in contact with you soon after receiving your information. Thank you. F amily S ource C onsultants, LLC 123 E. Ogden Ave. Suite 201A Hinsdale, Il 60521 Fax: 815-744-1681 info@familysourcesurrogacy.com Family Source Consultants, LLC Intended Parent Application 12