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Intended Parent Questionnaire (PDF)

This questionnaire is to be completed only AFTER you have completed your consultation and agreement with Family Source.

If you would like to schedule a consultation, please Request a Consultation.

Step 1 of 7

You are on your way to an amazing journey!

Please be as thorough as possible when completing your questionnaire, as this is the information that will be shared with potential surrogates. For tips on creating your Intended Parent Profile, please visit Creating Your Intended Parent Profile

To save and complete your questionnaire at a later date, please click the "Save and Continue Later" link at the bottom of the form.

When you save your form, you will be provided with a UNIQUE LINK to return to your form and complete the application process. Please be sure to save this link or email it to yourself in order to return to your form.

If you have any trouble completing the form, please email info@familysourceconsultants.com. We will be happy to assist you!

Do you have a partner or spouse?

Yes

I will be building my family with the help of

Surrogate

Egg Donor

Both Surrogate and Egg Donor

General Information, Intended Parent #1

Last Name

For FSC internal use only.

First Name

First INITIAL only

Middle Initial

For FSC internal use only.

Maiden Name

Nickname

Relationship to Partner #2

Date of Birth

Age

Gender

Male

Female

Non-binary

Sexuality

Heterosexual

Same Sex

Prefer Not to Answer

Home Phone

For FSC internal use only.

Work Phone

For FSC internal use only.

Cell Phone

For FSC internal use only.

Street Address

For FSC internal use only.

City

For FSC internal use only.

State/Province/Locality

For FSC internal use only.

Country

For FSC internal use only.

Postal Code

For FSC internal use only.

Email address

For FSC internal use only.

In case of emergency, contact (name & relation)

For FSC internal use only.

Emergency contact phone number

For FSC internal use only.

Race(s)

Ethnic Background(s)

Religious affiliation(s)

Where were you born?

Have you ever lived in another country?

Yes

Which country(s)?

Date(s) From-To?

What languages do you speak/write?

Did you attend college/university?

Yes

Name of school

Please list any degree(s) that you hold

Other licenses/certificates/areas of training, etc

What is your current occupation/position?

Are you currently employed?

Yes

Employer and position?

For FSC internal use only.

How long have you been working for the above employer?

Employer's Street Address

For FSC internal use only.

Employer's City, State

For FSC internal use only.

Employer's Zip Code

For FSC internal use only.

Have you been, or are you currently in the military?

Yes

Please specify and list dates

Have you ever had a major illness?

Yes

Please explain and list dates

Do you have any chronic medical conditions/problems?

Yes

Please explain

Do you have a criminal record of any kind?

Yes

Please explain and list dates

Have you ever been tested for HIV/AIDS?

Yes

Please list date(s) and result(s)

Have you ever suffered from severe depression?

Yes

Please explain and list date(s)

Have you ever been to see a mental health professional?

Yes

Please explain and list date(s)

Have you ever been prescribed psychiatric medication(s)?

Yes

Please explain and list date(s)

Do you drink alcohol?

Yes

How often?

Do you smoke cigarettes?

Yes

How often?

Do you use any illegal drugs?

Yes

Please specify

Please describe your personality in as much detail as possible. What are your positive and negative qualities?

What are your interests and hobbies?

Please describe your spouse/partner in as much detail as possible. Tell us about his/her personality, including positive and negative traits.

What kind of parent do you think your spouse/partner will be?

If you are a single Intended Parent, this page is intentionally blank. Please proceed to the next page!

General Information, Intended Parent #2

Last Name

First Name

First INITIAL only

Middle Initial

Maiden Name

Nickname

Date of Birth

Age

Gender

Male

Female

Non-binary

Home Phone

Work Phone

Cell Phone

Street Address

City

State/Province/Locality

Country

Zip Code

Email address

In case of emergency, contact (name & relation)

Emergency contact phone number

Race(s)

Ethnic Background(s)

Religious affiliation(s)

Where were you born?

Have you ever lived in another country?

Yes

Which country(s)?

Date(s) From-To?

What languages do you speak/write?

Did you attend college/university?

Yes

Name of school

Please list any degree(s) that you hold

Other licenses/certificates/areas of training, etc

What is your current occupation/position?

Are you currently employed?

Yes

Employer and position?

Current income

How long have you been working for the above employer?

Employer's Street Address

Employer's City, State

Employer's Zip Code

Have you been, or are you currently in the military?

Yes

Please specify and list dates

Have you ever had a major illness?

Yes

Please explain and list dates

Do you have any chronic medical conditions/problems?

Yes

Please explain

Do you have a criminal record of any kind?

Yes

Please explain and list dates

Have you ever been tested for HIV/AIDS?

Yes

Please list date(s) and result(s)

Have you ever suffered from severe depression?

Yes

Please explain and list date(s)

Have you ever been to see a mental health professional?

Yes

Please explain and list date(s)

Have you ever been prescribed psychiatric medication(s)?

Yes

Please explain and list date(s)

Do you drink alcohol?

Yes

How often?

Do you smoke cigarettes?

Yes

How often?

Do you use any illegal drugs?

Yes

Please specify

Please describe your personality in as much detail as possible. What are your positive and negative qualities?

What are your interests and hobbies?

Please describe your spouse/partner in as much detail as possible. Tell us about his/her personality, including positive and negative traits.

What kind of parent do you think your spouse/partner will be?

Family Details

What is your relationship status?

Single

Married

Not Married, but in a committed relationship

How long have you been in a committed relationship (list year)?

Do you have children?

Yes

Please list their gender(s) and age(s)

Which of the following ways did you grow your family?

Carried the baby (ies) yourself

Adoption

Surrogacy

Egg Donation

Please describe your home and neighborhood

Please describe your home life

What is the name & location of your fertility clinic?

Which doctor are you working with?

Will you use an egg donor?

Yes

Will you use a sperm donor?

Yes

Fertility History

Have you experienced fertility struggles before now?

Yes

How long have you been going through infertility?

Have you ever become pregnant with the assistance of an infertility clinic/ reproductive endocrinologist?

Yes

If yes, please list date(s) and explain

Have you ever had a miscarriage?

Yes

Please discuss anything you would like Family Source (and your potential Gestational Surrogate) to know about any fore mentioned infertility experiences.

Surrogacy Journey Details & Matching Criteria

How long have you been considering this route to parenthood?

Please describe when/how the idea to pursue surrogacy to build your family came to mind

How many attempts with a Surrogate will you be willing to try?

Please explain

If you are already parents via surrogacy, please tell us about this experience in as much detail as possible. Please include dates of pregnancy (ies) and delivery (ies)

Please discuss the qualities you believe to be most important in a Gestational Surrogate

Please list any circumstances which would cause you to NOT want to work with a potential Surrogate

How much contact would you like with your Gestational Surrogate throughout the pregnancy? Would you like her to occasionally send/email you pictures of herself and share details about the pregnancy? (Please be specific in describing what you have in mind, as we want to make sure you are matched accordingly.)

How much contact do you envision having with your Gestational Surrogate after the pregnancy and delivery? (Please be specific in describing what you have in mind, as we want to make sure you are matched accordingly.)

Are you interested in attending doctor appointments/ultrasound appointments with your Gestational Surrogate? (We understand that this will vary depending on location of the Intended Parent(s) and Surrogate.)

Yes

Please explain

Do you plan on filming or taking pictures of your Surrogate throughout this process?

Yes

Please explain

Would you like to be in the delivery room when your baby (or babies) is/are born?

Yes

Please explain

The following questions are ones that you and your future Surrogate must agree upon. It is most crucial that you answer these questions with all honesty, as it is pertinent in making sure you are matched appropriately.

Do you plan to transfer 1 or 2 embryos?

One

Two

One or Two

If after a single embryo transfer, it is confirmed that your Surrogate is carrying multiples, would you opt to selectively reduce (of course, taking your doctor's advice into consideration)?

Yes

Other

Please explain

If after a double embryo transfer, it is confirmed that your Surrogate is carrying triplets or more, would you opt to selectively reduce (of course, taking your doctor's advice into consideration)?

Yes

Other

Please explain

Will your embryos be genetically tested (PGS?)

Yes

Would you opt for early termination should your baby have a serious medical condition (Keep in mind, this determination would likely be made sometime around 12-16+ weeks)

Yes

Please explain

If it is determined that the baby has Down’s syndrome, would you choose to terminate the pregnancy?

Yes

Please explain

Do you wish for your Surrogate to live in a particular state? If yes, please list the desired state(s)

For FSC internal use only.

Would you accept a Surrogate who is a lesbian?

Yes

For FSC internal use only.

Would you accept a Surrogate who is of a different race/religion/cultural background than your own?

Yes

For FSC internal use only.

Please write a message to your future Gestational Surrogate

Do you authorize Family Source Consultants to share your photo(s) during the matching process with possible Gestational Surrogate candidates?

Yes

For FSC internal use only.

How did you learn about Family Source Consultants, LLC?

For FSC internal use only.