Intended Parent Questionnaire

NOTE: This information will only be shared with a prospective Surrogate with your approval. Please complete this questionnaire with as much information as you are comfortable sharing. This helps a candidate get to know you.

CONFIDENTIAL INFORMATION
This will be removed before sharing with a gestational surrogate.
Name *
Name
Best number for us to reach you: *
Best number for us to reach you:
PERSONAL INFORMATION
Intended Parent #1
Intended Parent #2 (If applicable)
Current relationship status: *
FERTILITY INFOMRATION
Do you have frozen embryos? *
Are you using an egg donor? *
Are you using a sperm donor? *
Do you have other children? *
SURROGACY INFORMATION
Do you have a preference for the state where your surrogate resides? All of our surrogates live in surrogacy friendly states. *
Do you plan to attend the Obstetrical appointments with your surrogate? *
If it is determined that your Child has physical or genetic abnormalities (including Down's Syndrome), would you plan to terminate the pregnancy? *
If the IVF process results in a multiples pregnancy, will you plan to selectively reduce if the doctor recommends this is the healthiest option for the surrogate and the baby(ies)? *
Would you be willing to work with a surrogate who will not submit to selective reduction? *
Do you want to be in the delivery room when your child is born? *
INTENDED PARENT #1 PROFILE
Please answer the following questions for Intended Parent #1
Are you a U.S. citizen? *
Your Parents
Your siblings
Do you have any current or past medical issues? *
Have you or your partner ever tested positive for Hepatitis B or C antibodies and or antigen (IGG or IGM)? *
Are you at risk for HIV or AIDS? *
To your knowledge, have any of your sexual partners in the last 5 years been sexually active with anyone in the high risk group for HIV/AIDS? *
Have you ever been formally or informally diagnosed with any mental health disorder (for example depression, anxiety, bipolar disorder)? *
Do you currently or have you ever taken medication for a mental health issue? *
Have you ever been hospitalized for a mental health issue? *
Have you ever been diagnosed with any of the following (please check)?
INTENDED PARENT #1 PERSONAL HISTORY
INTENDED PARENT #2 PROFILE (IF APPLICABLE)
Please answer the following questions for Intended Parent #2
Are you a U.S. Citizen?
Your Parents
Your siblings
Do you have any current or past medical issues?
Are you at risk for HIV or AIDS?
Have you ever been formally or informally diagnosed with any mental health disorder (for example depression, anxiety, bipolar disorder)?
Do you currently or have you ever taken medication for a mental health issue?
Have you ever been hospitalized for a mental health issue? *
Have you ever been diagnosed with any of the following (please check)?
INTENDED PARENT #2 PERSONAL HISTORY
The form may take a up to 60 seconds to process fully. When it is done, you will see a thank you page. Please only press the submit button once.
Please submit 4-5 photos of you and your family to apply@abcsurrogacy.com