**NOTE: This is just a preliminary screener application. You will be provided with a full application upon receipt of this form**
Has either applicant:
ever been arrested and/or convicted of a crime?
ever been cited for or convicted of any offense involving alcohol or drugs?
had your wages garnished?
filed a petition for bankruptcy?
had an involuntary petition for bankruptcy filed against you?
had a foreclosure action filed against you?
had a collection action of any kind filed against you?
had an eviction action of any kind filed against you?
If you answered yes to any of the above, please explain:
Has any life insurer or health insurer ever refused to issue you an insurance policy?
Does either applicant have a health condition which impairs normal daily activities, is likely to significantly reduce life span, or may impair the ability to care for a child?
Has either applicant been diagnosed with any disease or condition that required past treatment or requires current or future treatment?
If you answered yes to either, please describe the condition(s) and treatment(s), including medications and prognosis:
Has either applicant previously participated in a psychological or psychosocial evaluation with respect to an assisted reproduction procedure, such as surrogacy or egg donation?*
If you answered yes to either, please provide the name of the clinic and evaluator, and all contact information:**
**Please note that all Intended Parents are required to participate in a psychological or psychosocial evaluation with one of our mental health providers as part of the process of applying to The Surrogacy Center's program.
Are you currently working with a fertility clinic?
If so, please list (Clinic, Doctor, Nurse/clinic contact):
You plan to use:
Your own egg and spermEgg DonorSperm DonorOther
Do you already have embryos available?
If yes, how many?
How many embryo transfer attempts are you willing to undergo to achieve a successful pregnancy?
123more than 3
Are you willing to have the Gestational Carrier carry multiple fetuses?
If yes, how many?
Are you interested in a Gestational Carrier who would possibly carry another child for you in the future?
In what circumstances, if any, would you consider abortion or selective reduction? (Topic will be discussed in more detail when we meet):
Do you have any time constraints for being introduced to a potential Gestational Carrier?
Please list the characteristics that you are seeking in a Gestational Carrier:
Please describe the kind of relationship you expect or hope to establish with the Gestational Carrier (before, during and after the pregnancy):
Do you have any requirements or limitations regarding the woman who will carry your baby?
If so, please check all that apply:
Marital StatusSexual OrientationEthnicityReligionOther
Please explain limitations here:
Are you working with an attorney?
If so, please list attorney's name and contact information:
Please write a personal note or letter which describes you and your family. You may want to include details about your daily life and your family background. Please also send photos to share with potential Gestational Carriers.
Please upload pictures here:
Have you received and carefully looked at a copy of the Surrogacy Center's Cost Matrix?
Do you understand that the total cost of a surrogacy matter can range from approximately $75,000 to well over $100,000?
How do you intend to pay for the costs associated with a surrogate pregnancy? Check all that apply:
Personal SavingsSale of investmentsSale of real estate or real propertyLoan or Gift from family membersFinancing will be neededI/We have already applied for a loanOther
In terms of timing, which one best describes your situation?
I/we have the resources to proceed immediatelyI/we need additional time to secure the resources we will need
How did you hear about The Surrogacy Center?
Will you agree to keep The Surrogacy Center informed regarding any changes to any of the information you have provided on this application?
Is there anything else you would like to add?