IP – Prospects Questionnaire
Please complete all fields as accurately as possible
Intended Parent 1
First Name
*
Last Name
*
Email
Occupation
Ethnicity
Race
-Select-
White
Black or African American
Asian
Hispanic or Latino
Native American
Pacific Islander
Middle Eastern
Mixed
Other
Prefer not to say
Age
Health Status
Do you have any medical problems that are life threatening?
Yes
No
Do you smoke?
Yes
No
Do you drink Alcohol?
Yes
No
Have you ever been convicted of a crime?
Yes
No
Have you ever received psychiatric treatment?
Yes
No
Intended Parent 2 (if applicable)
First Name
Occupation
Ethnicity
Race
-Select-
White
Black or African American
Asian
Hispanic or Latino
Native American
Pacific Islander
Middle Eastern
Mixed
Other
Prefer not to say
Age
Health Status
Do you have any medical problems that are life threatening?
Yes
No
Do you smoke?
Yes
No
Do you drink Alcohol?
Yes
No
Have you ever been convicted of a crime?
Yes
No
Have you ever received psychiatric treatment?
Yes
No
About Your Family
How long have you been together (if applicable)?
What do you like to do in your spare time?
Who lives in your household in addition to you/yourselves?
Do you currently have any children?
Yes
No
Why did you decide to pursue family building through surrogacy?
Medical Preferences
Do you want to have sex selection performed?
Yes
No
If a multiple pregnancy occurs, would you want selective reduction performed?
Yes
No
Would you want to abort the pregnancy if the fetus had severe physical abnormalities?
Yes
No
Please explain:
Your Relationship with Your Surrogate
What reassurance can you give the surrogate that once the baby is born you will not change your mind?
What kind of relationship/contact would you like during the pregnancy?
What kind of relationship/contact would you like after the delivery?
Would you like to attend the obstetrical appointments with your surrogate?
Yes
No
Would you like to be in the delivery room when your child is born?
Yes
No
If you are not present for your child's birth, would you like photos to be taken?
Yes
No
Will you tell your child about the surrogate, and what role she played in your life?
Yes
No
How would you feel about your child meeting the surrogate?
What qualities do you find most important in your surrogate?
Your message to your surrogate:
Photos & Documents
Please add at least 3 photos that show the best sides of you
Choose File(s)
Save
Submit
