Lauren Magalnick Berman, Ph.D.

Clinical Psychologist
One Premier Plaza, Suite 600
5605 lenri!ge Dri"e
#tlanta, eorgia $0$%&
Ph. %0%'6$%'&555 (a) %0%'&5*'0&++
Thank you for your interest in becoming a gestational carrier. The gift of a child is very
precious for couples who are struggling with infertility challenges. You and I will be
meeting for a clinical interview during which we will discuss many things about you.
After the clinical interview, you may be given a psychologist test. Please allot 2 to 2
hours for this process. !ollowing our meeting, I will prepare a report.
The procedures are designed to help ascertain whether you will make a good gestational
carrier candidate. A key goal is to help you understand the process that you will undergo
and to ensure that being a gestational carrier will be a positive and healthy e"perience for
you. The information obtained in the assessment will give potential couples the chance
to know more about you. #hen couples choose a carrier, they often choose someone
whom they feel connected to in some special way. $y report will help them know more
about you as a person. Your history, goals, struggles, interests, talents, humor,
relationships and other uni%ue characteristics are the kinds of things with which couples
can identify.
&y agreeing to complete the carrier assessment today, you are also agreeing to allow me
to review the assessment material and provide a written report to the appropriate staff at
'''''''''''''''''''''''''''''''''''''''. You will not have access to the
findings or the report. Please feel free to ask me to clarify any information covered in
this document. All %uestions are good ones.
I, ''''''''''''''''''''''''''''''''''', agree to participate in all procedures in the
gestational carrier assessment in an honest and thorough fashion. I understand that the
findings and the report will be sent directly to the appropriate staff at
''''''''''''''''''''''''''''''and a recommendation will be shared with the
couple that intends to contract with me. I waive all rights to the material.
(ame''''''''''''''''''''''''''''''''''' Age''''''''''''''''''''
#itness''''''''''''''''''''''''''''''''' )ate''''''''''''''''''''
Thank you for your candid responses. *$&
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GESTATIONAL CARRIER/SURROGATE QUESTIONNAIRE
Name_______________________________________ Date_______________________
Address________________________________________________________________
Phone Number (Ce or home! _____________________________________________
"e#$ht_________ %e#$ht___________ E&e Coor__________ "a#r Coor__________
The purpose of this questionnaire and the clinical interview that follows is to help you
understand as fully as possible the meaning and long-term implications of your
decision to become a surrogate or gestational carrier to an individual or couple. It is
also designed to be sure that you are emotionally and psychological prepared to do
this. Please answer honestly and completely and jot down any questions that you
might have and bring them to the interview. THA!".
SEL' REPORT
Please describe yourself.
#hat do you feel are your best %ualities,
#here, if at all, do you feel you would like to improve,
#hat sports, hobbies or special interests do you have,
#hat are some things that make you happy or satisfied,
#hat kinds of people do you like the most, The least,
2
)escribe a situation where you had to work hard to achieve a goal. -ow did you do it,
#hat are your religious affiliations, if any,
LI'E STRESS AND COPING S(ILLS
)o you consider yourself to have a stable lifestyle,
Y./'''''' (0'''''
If you have answered (0, please e"plain1
#hat kinds of stress do you encounter in your current life,
#hat strategies do you use to manage your stress,
-ow do you deal with criticism,
)escribe your support system 2friends, family, religious or volunteer community, etc3
)escribe any significant losses regarding people or events in your life.
#hat happened and at what age did this occur,
-ow did you feel at the time, -ow do you feel about it now,
Please describe any health problems you have had in your life.
ALCO"OL AND DRUG "ISTOR)
-ave you ever smoked cigarettes, Y./ or (0 24ircle one3.
If Y./5
6
At what age did you begin to smoke,
At what age did you %uit,
)o you currently smoke,
-ow many packs of cigarettes do you currently smoke per day,
)oes anyone else in you household currently smoke cigarettes, Y./ or (0
-ave you ever used recreational drugs, Y./ or (0 24ircle one3
If Y./5
#hich drugs have you used,
)o you currently use any of these drugs, #hich ones, -ow often,
)o you ever drink alcoholic beverages, Y./ or (0 24ircle one3. Y./ or (0 24ircle
one3.
If Y./5
-ow often do you drink,
-ow much do you drink in one evening,
-ow old were you when you first tried alcohol,
-ave you ever e"perienced a &lackout, Y./ or (0 24ircle one3.
-ave you ever been arrested for )7I, Y./ or (0 24ircle one3.
-ave you ever e"perienced )Ts, Y./ or (0 24ircle one3.
)o you have any family members who have been alcohol8 or drug8addicted, Y./ or (0
If Y./5 #ho,
'A*IL) +AC(GROUND
#here were you born, #here were you raised,
#ho raised you,
9
)escribe your relationship with your parents and siblings.
#hat positive e"periences did you have as a child,
#hat negative e"periences did you have as a child,
)escribe your childhood.
)id you e"perience any physical, se"ual or emotional abuse as a child or young adult,
Y./ or (0
-ave you e"perienced any significant losses in your life, Y./ or (0 24ircle one3.
If Y./5 #hat were they and when did you e"perience them,
OT"ER RELATIONS"IPS
Are you currently married, engaged or in a committed relationship, Y./ or (0
If so, for how many years,
)escribe your relationship with your spouse:partner 2e.g. happy, strained3.
-ave you e"perienced significant marital problems,
-ow do you and your spouse:partner deal with conflict and adversity,
-as your spouse:partner e"perienced any significant losses, Y./ or (0 24ircle one3
If Y./, please describe.
-ave you been previously married, Y./ or (0 24ircle one3
If Y./, please list the dates of the marriage and termination of that marriage.
-ow did the loss of this marriage affect you,
;
Please describe your current significant friendships.
%OR( AND EDUCATION
)escribe your educational background.
#hat is your most recent grade point average,
*ist your degree2s3, if any.
#hat do 2did3 you en<oy about school,
#hat is 2was3 your ma<or,
#hat kind of work do you do,
-ow long have you been at your current employer,
-ow long have you been in your current position,
#hat are your plans for the future,
'INANCIAL STATUS
Are you 5 !inancially comfortable, 0n a tight budget,
24ircle all that apply3
/ignificantly in debt, =epaying student loans,
Are you currently receiving any form of public assistance, Y./ or (0
-ow well do you manage your money,
LEGAL ISSUES
)escribe any circumstances on which you have had legal issues or contact with the law.
>
-as anyone in your family or household ever been arrested, Y or (
If so, whom for what,
-ave you ever been sued, Y or ( /ued another party, Y or ( 4onsulted an attorney,
Y or (
If Y./, please describe.
)o you wear a seatbelt1 A*#AY/ 0!T.( /0$.TI$./ (.?.=
*EDICAL "ISTOR)
)o you have any significant medical problems, Y./ or (0 24ircle one3.
If Y./5please describe.
)o you take any medications, Y./ or (0 24ircle one3.
If Y./, list the medication2s3 and reason for taking them,
)o you have any allergies, Y./ or (0 24ircle one3.
If Y./, to what,
-ave you gotten any tattoos or body piercing within the last si" months, Y./ or (0
)o you have health insurance, Y./ or (0
REPRODUCTI,E E-PERIENCE AND SE-UAL "ISTOR)
-ave you ever been pregnant,
If Y./5 -ow many times,
#hat was your relationship with the father2s3,
#ere there any pregnancy health related issues,
#hat was the outcome of each pregnancy 2e.g live birth, miscarriage,
abortion, stillbirth3,
#ere any of your children born at a very high or very low weight, Y or (
If yes, please e"plain1
@
#ere any of your children born prematurely, Y./ or (0 If yes, please
describe1
#ere any of your children delivered by 48section, Y./ or (0
If yes, what was 2or were3 the reasons for the 48section2s31
Is it your understanding that future births will also be by 48section, Y./
or (0
-ave you had other complications with any pregnancy or birth, Y./ or
(0
#hat were your feelings about each pregnancy,
)o you want to have children in the future, Y./ or (0 24ircle one3
)o you and:or your spouse:partner have any children living at home, Y./ or (0 24ircle
one3.
If Y./5describe your relationship with the children.
Are any of your children or your spouseAs children living outside the home, Y./ or (0
If Yes, please e"plain1
-ave you ever had any infertility problems, Y./ or (0 24ircle one3.
-as anyone in your family had any infertility problems, Y./ or (0 24ircle one3.
)escribe your se"ual history.
Are the following people supportive of your becoming a gestational carrier,
Parents, Y./ or (0 or -A?. (0T &..( T0*) 24ircle one3.
/pouse:Partner, Y./ or (0 or -A/ (0T &..( T0*) 24ircle one3.
!riends Y./ or (0 or -A?. (0T &..( T0*) 24ircle one3.
Is anyone Bstrongly encouragingC you to become a gestational carrier, Y./ or (0
24ircle one3.
If Y./, is this causing you any confusion or discomfort,
D
PS)C"OLOGICAL "ISTOR)
-ave you ever e"perienced a depression, Y./ or (0 24ircle one3.
If Y./5&riefly describe.
-ave you ever had an"iety attacks, Y./ or (0 24ircle one3.
If Y./5&riefly describe
-ave you ever seen a psychologist, counselor, psychiatrist or therapist, Y./ or (0
24ircle one3.
If Y./5 #hen,
!or how long,
!or what reason,
#hat did you learn from your e"perience,
-ave you ever taken psychiatric medications, Y./ or (0 24ircle one3.
If Y./5Please list
-ave you ever been hospitaliEed for emotional problems, Y./ or (0 24ircle one3.
)oes anyone in your family have any mental or emotional issues, Y./ or (0 24ircle
one3.
UNDERSTANDING O' GESTATIONAL CARRIER/SURROGAC) AND
RESPONSI+ILITIES
In which capacity do you wish to serve,
Festational 4arrier 2using embryo transfer3'''''''''''' or
/urrogate 2using your egg and artificial insemination '''''''
-ave you previously served as a surrogate:gestational carrier, Y./ or (0
If yes, please describe your e"perience1
Are you willing to travel for any surrogacy8related procedures, Y./ or (0
G
Are you comfortable with the information given to you by the fertility center, Y./ or
(0 24ircle one3.
)o you know someone who has been a gestational carrier, Y./ or (0 24ircle one3
If Y./5 #hat was her e"perience like,
#hy do you want to be a gestational carrier,
#hat will you do with the money you receive from the procedure,
)escribe your work or school schedule. )o you have fle"ibility,
#hat do you know about the procedures, drugs, schedules and timelines involved in
being a carrier or surrogate,
-ow do you feel about taking daily medications,
-ow do you feel about possibly receiving daily in<ections for an e"tended period of time,
Are you willing to give up cigarettes, alcohol, drugs:medications, caffeine and dangerous
activities prior to and during the surrogacy:carrier arrangement, Y./ or (0
Are you willing to undergo amniocentesis or chorionic villi sampling if the intended
parents re%uest it and your physician approves, Y./ or (0
If your physician recommended bed rest, would this be a problem for you, Y./ or (0
Are you willing to carry multiple fetuses, Y./ or (0 If yes, how many,
-ow many embryo transfers are you willing to undergo in order to achieve a successful
pregnancy and birth,
Are you morally comfortable with abortion, Y./ or (0 24ircle one3.
If Y./5 7nder what circumstances,
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Are you morally comfortable with selective reduction 2medically aborting one or more
embryos for medical or health8related reasons3, Y./ or (0 24ircle one3.
If Y./5 7nder what circumstances,
7nder what circumstances, if any, would you agree to abortion or selective reduction,
Please indicate for whom you might be willing to carry a child 2$A=I A** T-AT
APP*Y3
''''heterose"ual married couple
''''heterose"ual unmarried couple
''''single female
''''single male
''''gay or lesbian couple
''''someone who is ethnically different from you
''''someone who has a different religion from you
''''someone who lives in a different state from you
''''someone who lives in a foreign country
Please list the characteristics you are seeking in Intended parents 2i.e. family background,
occupations, religions, education, personality, values, etc3
Please describe the kind of relationship you hope to establish with the Intended Parents
before, during and after the pregnancy.
Please describe the kind of relationship you hope to have with children born from this
process1
)o your husband, partner, family members, and:or friends have any concerns about your
becoming a surrogate:carrier,
Is your husband or partner aware of his or her responsibilities in the medical process and
how this will impact your relationship and family life,
)uring and after the surrogacy:carrier process, from whom can you e"pect to receive
emotional support,
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#ho will be with you during the birth,
#hat is your understanding of the health risks of the medical procedures you will
undergo and pregnancy and childbirth,
)escribe any concerns or fears you may have regarding becoming a surrogate:carrier.
)o you know what will happen to any embryos that are ultimately unused,
#rite down any %uestions or concerns you have about moral, ethical or legal issues
related to the gestational carrier procedure.
#rite down any %uestions or concerns you have about emotional issues related to being a
gestational carrier.
#rite down anything else you would like to share about yourself.
#rite down any other %uestions you would like to discuss today.

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