If you have been at your current address for less than 5 years, please list previous residence(s) for the past 5 years:
Are you currently on any form of public assistance? * Select Yes No
If Yes, What?
Have you ever been a surrogate mother? * Select Yes No
Have you ever been an egg donor? * Select Yes No
Do we have your permission to contact the agency agencies? * Select Yes No
I will work with * Select Anyone, No Restrictions Foreign Couples
Is there anyone you prefer not to work with? Please be specific. *
How did you hear about our program? *
Dates of all Previous Marriages
Have you or your spouse/significant other ever had any problems with the law (ie. DUI, custody issues, lawsuits)? * Select Yes No
If yes, please describe
Please list any arrests, convictions, sentences, etc
Have you ever been incarcerated? * Select Yes No
If yes, please describe
Have you or anyone living in your home ever been arrested or investigated for intent to harm or neglect of a child? * Select Yes No
If yes, please explain and give dates and results (You must provide a copy of the CPS report with your application.
If not married, who will be your support during your pregnancy and after the birth of the child? *
Do you intend to remain employed during your pregnancy? * Select Yes No
Do you own a family pet? * Select Yes No
If yes, What kind?
Has your pet had all of his/her vaccinations? Select Yes No
Have you ever had any major illnesses such as amoebic dysentery (infection of intestine), hypertension, blood clots, pneumonia, mononucleosis, etc? * Select Yes No
If yes when and what?
Have you had any serious illness in the past? * Select Yes No
If yes, please describe
Do you have any complications or concerns with anesthesia? *
Have you had any hospitalization(s) not mentioned above? *
Please list any surgical procedures:
Have you experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician (Please include those symptoms that you may not consider serious.) * Select Yes No
If yes, please describe
Have you ever been seen by a psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason? * Select Yes No
If yes, when, for how long and for what reason?
Have you ever had any therapy with a psychiatrist or any other health care professional? * Select Yes No
If yes, please give prognosis, diagnosis and dates
Have you ever used medications such as anti-anxiety or anti-depressants to treat an emotional or psychological problem? * Select Yes No
If yes, list why and date last used
Have you ever been institutionalized in a mental hospital facility, whether voluntarily or involuntarily? * Select Yes No
If yes, please give prognosis, diagnosis and dates
If you have checked any of the above please explain
How long have you been in recovery?
Sexual Orientation * Select Homosexual Heterosexual Bisexual
Number of current sexual partners *
Total number of past sexual partners *
Number of sexual partners during the last six months *
In the last 6 months, have you had unprotected sex (intercourse without a condom) with a new partner? * Select Yes No
Have you ever injected drugs or had a sexual partner who did so? * Select Yes No
Do you or your spouse/significant other have any sexually transmitted disease or have you ever tested positive for any sexually transmitted disease? * Select Yes No
If yes, please describe when and method of treatment?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
If Yes, When?
How Many Times?
When was the last?
You always have the right to terminate (abort) a pregnancy if your health is at risk. However, if the fetus had a fatal or significant abnormality, would you be willing to terminate at the parent’s request? * Select Yes No
If there is no health risk, I am willing to carry triplets: * Select Yes No
If I became pregnant with triplets, I would agree to selective reduction at the request of the couple: * Select Yes No
The doctor who will perform the IVF or insemination will need to have access to your medical records from the birth(s) of your child(ren). Can these be made available? * Select Yes No
