The Surrogacy Program
Shelley B. Smith M.A., M.F.C.C.

4184 Colfax Ave.
Studio City, CA 91604
Fax: (818) 506-9763 Phone: (818) 506-9300

• • • The information contained in these pages will be kept confidential • • •

 

 
 
Date : July 04, 2008
Name :
Partner #2 : Partner #1 :

Address 1 :

Address 2 :

(w) Phone # : (h)

Email :

(Partner #1) SS# (Partner #2) SS# Occupation :
(Partner #1) : (Partner #2) : Age :
Status : Married       Single       Committed Relationship       How Long?

Who is your fertility specialist?

Will spouse/partner be the biological father? Yes       No

If no, is the sperm donor     known       or unknown

How did you hear about The Surrogacy Program?

Are you in need of an egg donor? Yes       No

 
 

 
 

Previous Children :

Ages :

 

 

Partner #1 :

Partner #2 :

  
 

 
 

Physical Characteristics :

Height :

Weight :

Hair :

Eyes :

Ethnicity :

Partner #1 :

Partner #2 :

  
 

 
 
Educational Background :

Partner #1 :

Partner #2 :

Please describe your personality with 4 or 5 adjectives:

Partner #1 :

Please list your interests, hobbies and activities :

Please describe your personality with 4 or 5 adjectives:

Partner #2 :

Please list your interests, hobbies and activities :

Please list several qualities that you would consider to be important in a surrogate:

How much contact do you plan to have with the Surrogate?

Phone calls?       Yes       No       Number per month:
 
 

 
 

Yes       No Doctor's Visits?

Yes       No Embryo Transfer?

During Conception Process:

Yes       No Monthly Doctor's Visits?

Yes       No Ultrasound?

During Pregnancy:
How much time to you want to spend with the Surrogate and her family?
Birth:

Yes       No Partner #1 :

Yes       No Partner #2 :

Do you want to witness the birth?

Yes       No
Do you want to take still photos?

Yes       No
Do you want to videotape the birth?

Yes       No
Can the Surrogate hold the baby at some time while in the hospital?

We wish to have a :       BOY       GIRL       EITHER
How long have you been trying to achieve pregnancy?
How long have you been married or together?
Keeping in Touch:

Yes       No Soon after the birth :

Yes       No Yearly - Holidays :

Yes       No Yearly - Child's birthday :

Will you maintain contact :

Yes       No Pictures :

Yes       No Letters :

Will you send :

Yes       No
Will you allow a visit by the child to your surrogate at a later date?

Other :
 
 

 
 
Background Information:
1) What would you most like your surrogate to know about you?
2) What is your home life like?
3) Are you close with your families?
4) What kind of infant care will you have?
5) What are your religious backgrounds/beliefs?

Partner #1 :

Partner #2 :

Additional information or comments :
How many years have you experienced infertility?
How long have you been considering surrogacy?
Please answer the following questionnaire on a scale ratio 1-5, 5 being highest :
Partner #2 : Partner #1 :    
• your comfort level with the procedure
• your level of hopes for success
• your satisfaction in the marriage/relationship
• commitment to becoming a parent
• level of depression regarding infertility
• level of anxiety regarding infertility
• level of guilt regarding infertility
• how you are coping with your infertility

Do you have any history of serious medical problems or infectious diseases?
If yes, what are they?
Have you had previous individual or group therapy to help support you during your infertility?
If so, how long?
What kind?
Yes     No Have either of you been accused and or convicted of a crime in any way related to child abuse?
Yes     No Have either of you been accused and or convicted of ANY crime?
If so, please explain?
 
 

 
 

I hereby certify that all of the above information is correct :

Full Name :

Partner #1   Date

Partner #2   Date

 
 
You will be counseled regarding donation issues. Outside referrals will be given independent psychotherapy when appropriate. Please do not hesitate to call with your questions and concerns. Good Luck!