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Questionnaire: Surrogacy Application

Deciding on the right surrogate mother is a challenging endeavor. The decision is fraught with emotional and legal implications. You may feel overwhelmed as you weigh pros and cons of such an important decision. The best advice anyone can give you is not to hurry through the process - take the time to gather all the information you need. Interviewing a potential surrogate mother is crucial in this process.

Factors to Consider When Interviewing a Surrogate Mother

There are many factors that determine whether a woman is the right person to carry your child: her physical health, genetics, emotional well being, and support network all have a bearing on the development and well being of your child. Beyond that, you also have medical, legal, and financial considerations to keep in mind.

Raising these questions early in the interviewing process will help you quickly narrow down surrogates who share your vision of the future and your family.

The following questionnaire can serve as a helpful tool in your determination of whether a particular candidate could be the right choice for you. Your attorney can help alert you to possible red flags, serve as an objective advisor, and draft the surrogacy contract once you have made your decision.

Name _______________________________________________________________________

Address _____________________________________________________________________

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Home telephone number _________________________________________________________

Work telephone number _________________________________________________________

E-mail address _________________________________________________________________

Age ________________

Education ____________________________________________________________________

Occupation ___________________________________________________________________

Employer ____________________________________________________________________

Marital Status _________________________________________________________________

If married, does your husband support your decision to become a surrogate? ________________

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Height ________________________

Weight ________________________

List all medications currently taken _________________________________________________

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List all surgeries and hospitalizations in last 10 years __________________________________

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List all known health problems ____________________________________________________

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Do you suffer from mental illness? _________________________________________________

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Do you have any sexually transmitted diseases? ______________________________________

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Have you ever been tested for AIDS and/or HIV? __________   Results ___________________

Do you consume alcohol? _____   Quantity __________________________________________

Do you smoke? _____   Quantity __________________________________________________

Do you now or have you ever used illegal drugs? _____________________________________

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List all known health problems of your parents and siblings

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Do you have children? _____   List ages ____________________

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List all health concerns relating to your children

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Did you have normal pregnancies? _____

  If not, explain ______________

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Did you suffer from post-partum depression?

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What do you expect will be the impact on your children of your surrogacy?

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Why do you want to be a surrogate?

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Will you allow the prospective parents to be involved during the pregnancy?

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Will you allow the prospective parents to be present at the delivery?

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Are you willing to undergo an extensive physical examination and psychological assessment before entering into the surrogacy arrangement?

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Do you have health insurance? ____________________________________________________

Are you willing to execute a surrogacy contract that dictates certain behaviors in which you must engage or from which you must refrain during the pregnancy?

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Are you willing to relinquish all claims to the child that is born as a result of the surrogacy arrangement?

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Hiring an Attorney

Surrogacy laws are constantly changing. A skilled family law attorney can help draft an enforceable surrogacy contract that addresses the important issues and the contingencies that could arise before, during, and after the pregnancy. With an attorney on your side, you stand the best chance of achieving your objective-having a child. Most offer free consultations, so your first step should be to contact an experienced family attorney.

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

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