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Intake Form: Birth and Infertility

When embarking on a path to parenthood that involves issues of infertility, many legal concerns may arise, and the support and advice of an experienced attorney is therefore invaluable. Some family law attorneys focus on the areas of assisted reproductive technology and surrogacy. The best approach is to forge a partnership with your attorney so that he or she can help ensure the most satisfying outcome for your family. In order to do so, you will need to provide your attorney with a vast amount of information. You can expedite the process by completing the following questionnaire before your first meeting with your lawyer.

Although some of the requested information may appear to go beyond the scope required in infertility-related cases, it is needed if the matter proceeds to adoption. In surrogacy cases, for instance, it may be necessary for one or both prospective parents to adopt the child after it is born, if they are not biologically related to the child, in order to secure their parental rights.

 

PROSPECTIVE MOTHER

Name: ________________________________

Date of Birth: __________________________

Social Security Number: __________________

PROSPECTIVE FATHER

____________________________________

____________________________________

____________________________________

Address(es), Including County:

 

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Length of Time at that Address:    _______ years

_______ years

 

Previous Address(es) (for last 10 years):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Home Telephone Number: ____________________

______________________________

 

Work Telephone Number: ____________________

______________________________

 

Facsimile Number : ____________________

______________________________

 

E-mail Address: ____________________

______________________________

 

Former Name(s): ____________________

______________________________

 

Employers: ____________________

______________________________

 

Position: ____________________

______________________________

 

Employer's Address

_______________________________

____________________________________

 

_______________________________

____________________________________

 

_______________________________

____________________________________

 

Length of Time with Employer: _______ years

_______ years

 

Previous Employer(s) (for last 10 years):

_______________________________

____________________________________

 

_______________________________

____________________________________

 

_______________________________

____________________________________

 

_______________________________

____________________________________

 

Gross Monthly Income: $_________________

$_________________

 

Other Income:

Source/Amount: ________________________

_________________________

 

Source/Amount: ________________________

_________________________

 

Source/Amount: ________________________

_________________________

 

Date of Marriage: _________________________________

Place of Marriage: ________________________________

Previous Marriage(s): Yes ____ No ____

Yes ____ No ____

 

Ended by:

Ended by:

 

Death ____ Divorce ____ Date _______

Death ____ Divorce ____ Date _______

 

Death ____ Divorce ____ Date _______

Death ____ Divorce ____ Date _______

 

Children of Current Marriage

Name Date of Birth Birth or
Adoption?
Living in home?
Yes/No
Race/
Nationality
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________

Children from Other Marriages or Relationships

Name Date of Birth Birth or
Adoption?
Living in home?
Yes/No
Race/
Nationality
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________
_______________ _________ _______________ _____________ _______________

I/we am/are interested in (check all that apply):

Assisted Reproductive Technology _____    Donor Eggs _____    Donor sperm _____

Gestational Surrogacy (Using Prospective Parents' Eggs and Sperm) _____

Surrogacy Using Surrogate's Eggs and Prospective Father's Sperm _____

Surrogacy Using Donated Eggs and Prospective Father's Sperm _____

Surrogacy Using Donated Eggs and Donated Sperm _____

Identify below any qualifications you have for egg/sperm donors, as applicable.

Race or ethnicity: ______________________________________________________________

______________________________________________________________________________

Health considerations: ___________________________________________________________

______________________________________________________________________________

Physical characteristics (including eye color, hair color, skin tone, height, weight, etc.):

______________________________________________________________________________

______________________________________________________________________________

Mental or emotional requirements: _________________________________________________

______________________________________________________________________________

Age: _________________________________________________________________________

Location: _____________________________________________________________________

Degree of involvement you wish to have in the pregnancy:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____ Wish to attend prenatal care appointments

_____ Would like surrogate to live in our home during some or all of pregnancy

_____ Want to be present at the birth

I/we have the following amount available to fund the procedure/surrogacy (may affect options that can be pursued):

Up to $1,000 _____   $1,000 to $5,000 _____   $5,000 to $10,000 _____

$10,000 to $20,000 _____   $20,000 to $30,000 _____   Over $30,000 _____

My/our medical insurance will cover _____% of the cost of assisted reproductive technology procedures.

Do you have a completed home study?   Yes _____   No _____

Has an adoption ever been denied to you?   Yes _____   No _____

Have you ever been arrested?   Adoptive mother: _______    Adoptive father: _______

If yes, explain: _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Are you in good health?   Adoptive mother: ________    Adoptive father: _______

Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you have a history of alcohol or drug abuse?   Adoptive mother: ________     Adoptive father: ________

List three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.

Name Address Relationship How long known?
______________ ____________________ _______________ ______________
______________ ____________________ _______________ ______________
______________ ____________________ _______________ ______________
______________ ____________________ _______________ ______________

Other Important Information:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Questions to Ask My Attorney:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Next Steps
Contact a qualified family law attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

Help Me Find a Do-It-Yourself Solution