Dear Prospective Surrogate,
Thank you for your interest in the Surrogate
Parenting Center of Texas, Inc. It takes a very special person to consider such
a generous gesture. Women with such
kind hearts make this dream a reality for infertile couples.
We require rigorous screening of all
surrogates. You will be asked to
undergo a psychological evaluation and, if selected, extensive counseling
throughout the gestational surrogacy arrangement. This is a very big commitment and sacrifice on your part and we
want to make sure you are adequately prepared for what may be ahead!
We do NOT
provide traditional surrogacy arrangements for our couples in which the
surrogate uses her own egg. Our couples
are required to use either the wifes eggs or donor eggs. The surrogate is NEVER biologically related to the baby she carries for another
couple.
Surrogates are compensated for their time,
inconvenience, discomfort and services on a monthly basis. The payments are disbursed over a ten-month
period (nine months of pregnancy and one month following delivery). Surrogates are also reimbursed travel and
other related expenses.
Please look over the enclosed information, Print and
fill out the application and call to schedule an initial visit. Feel free to contact us by phone at the
above listed number or by e-mail at caplanspct@aol.com.
Kindest
Regards,
Merritt
Morrison Turner, SWA Sheryl
Mink Caplan, Ph.D.
Director Licensed
Psychologist
Confidential
Surrogate Mother Application
Date of application: ____/____/____ Application Number:_______________
(for SPCT use only)
Last Name: _________________________ First Name:________________________
Middle Initial: ___
Maiden Name: _____________________________ Age: ________
Date of Birth: _____/_____/_____
Spouses Name: __________________________________His Age: _____
Date of Birth ____/____/____
Present
Address: _______________________________________________________________________
Street/Apartment number City State Zip
How Long at Current Address?:_____ If less than one year, please list previous address:
_________________________________________________________________________________
Street/Apartment number City State Zip
Phone: Home (______) ______-________ Work (______) ______-________
Pager (______) ______-________ Cellular (______) ______-________
e-mail address: ____________________________
Marital Status: Single Married Separated Divorced Widowed
U.S. Citizen: Yes No Social Security Number: ______-____-________
Drivers License Number: _____________________________ State: ________________________
Occupation: ___________________________________________________________________________
Employer: ____________________________________________________________________________
Employers Address: ____________________________________________________________________
How long with current employer?:____ If less than one year, provide previous employer information below.
Previous Employer:______________________EmployersAddress:________________________________
Spouses Occupation: ___________________________________________________________________
Spouses Employer: _____________________________________________________________________
In case of emergency please contact: ________________________________________
(Name and relation to surrogate)
________________________________________
(Phone Number)
Dates of all marriages:____________________________________________________________________
Dates of all divorces:_____________________________________________________________________
City, County and State of all Marriages:_______________________________________________________
Medical Insurance: Yes No
Insurance Company: ______________________________________ Policy Number: ________________
Physician: ____________________________________________________________________________
Physician Address: _____________________________________________________________
How did you hear about Surrogate Parenting Center of
Texas, Inc.? ________________________
Physical/Personal Data:
Age :
__________ Height:
_______ Weight: ________ Eye color: _______
Hair Color:
__________________
Race: _____________________________ Religious Affiliation: __________________________
Have you ever been convicted of a felony? Yes No
If yes, please explain: ____________________________________________________________
Have you ever declared bankruptcy? ________
If yes, please explain:
___________________________________________________________
Educational History (Please check all that apply):
ž Completed Grade School
ž Completed High School
ž Currently in College
Pursuing Degree in: __________________________________________
Name of
College/University:_______________________________________________________
ž Completed College Degree
in:
__________________________________________________
ž Currently Pursuing Advanced
Degree in:
__________________________________________
Name of
College/University:_______________________________________________________
Completed Advanced Degree
in:
________________________________________________
Fertility History:
Number of Pregnancies: _______ Dates of Pregnancies: _________________________
Number of Miscarriages: _______ Dates of
Miscarriages: _________________________
Number of Abortions: _______ Dates of
Abortions:
_________________________
Number of Stillbirths: _______ Dates of
Stillbirths:
_________________________
Number of Children:
_________
Names Birth
Date Sex
of Child Health/
Problems
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Did you have any pregnancy or delivery
complications? Yes๐ No๐ Please explain:____________
______________________________________________________________________________
What date did your last period begin? ____/____/____ and end? ____/____/____
Are your menstrual periods regular? Yes No How long is your monthly
cycle? ______
How many days does your period usually last? ___________________________________
How old were you when you started your period? ________________________________
Have you been an egg donor or a surrogate
before? Egg donor: Yes No
Surrogate: Yes No
Have you ever been told you were infertile? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
What form of birth control are you currently
using? _______________________________
Is there any history of fertility problems in your
family? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Did it take more than six months to conceive your
children? Yes๐ No๐
Did your mother take diethylstilbestrol (DES) or any
prescription drug while she was pregnant with you or any of your siblings? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Personal Health History:
Do you smoke cigarettes? Yes No If yes, how many a
week? _________________
Does anyone in your household smoke cigarettes? Yes๐ No๐
Do you drink alcohol: Yes No If yes, how much do you
drink? _________________
Are you using marijuana now? Yes No If yes, how often? ___________________
Have you ever used illegal or harmful drugs not
prescribed to you? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Have you ever had an eating disorder? Yes No If yes, please explain: ____________
Do you have a fear of injections? Yes๐ No๐
Have you ever had therapy with a psychiatrist, other
mental health professional or clergy member?
Yes No If yes, when and why: __________________________________________
________________________________________________________________________
Have you ever been prescribed psychiatric medication? Yes๐ No๐ If yes, when and why:
_________________________________________________________________________
Have you ever been hospitalized for a psychiatric
related issue? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Do you
currently have any allergies? Yes No If yes, please explain: _____________
________________________________________________________________________
What is your blood type? ___________________________________________________
Your diet is:
Vegetarian Non-vegetarian
How would you describe your diet? Poor Average Excellent
How much do you exercise? None Occasionally Regularly Athlete
What type of exercise do you participate in? ___________________________________________
Have you ever had surgery? Yes No If yes, please explain: ____________________
________________________________________________________________________
Have you ever had any hospitalizations not already
mentioned? Yes No If yes, please explain: _________________________________________________________________
Have you ever had a sexually transmitted
disease? Yes No If yes, please explain: ___
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever had any major illness not already
discussed on this application? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Do you have any chronic medical problems or
conditions? Yes No If yes, please explain:
_________________________________________________________________
________________________________________________________________________
Do you have any brothers or sisters who died in
infancy or early childhood? Yes No
If yes, please explain: ______________________________________________________
________________________________________________________________________
Personal and Motivational: Remember to use more paper if necessary!
In your own words describe your personality and
character: ________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your talents, ___________________________________________
Hobbies, and____________________________ Interests? ___________________________________________
If you could pass on a message to the child you will
deliver for a couple what would it be?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Why do you want to be an surrogate? _________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you foresee any possible emotional reactions or
problems you might have during the surrogacy process? ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you discussed surrogacy with anyone in your
family? Do they approve? __________________
______________________________________________________________________________
______________________________________________________________________________
Who would you have to provide emotional support
during the surrogacy process and would they be willing to fill that role?
___________________________________________________________
_____________________________________________________________________________
Tell us how your husband or partner feels about your
decision to become a surrogate mother:_____
_____________________________________________________________________________
_____________________________________________________________________________
What level of contact do you desire to have with the
couple during the pregnancy?_____________
_____________________________________________________________________________
What level of contact do you desire to have with the
couple and/or resulting children after delivery?
_____________________________________________________________________________
_____________________________________________________________________________
Tell us about the couple you would like to be a
surrogate for:______________________________
_____________________________________________________________________________
_____________________________________________________________________________
We will require some counseling for you during the
surrogacy process. How do you feel
about this?
_____________________________________________________________________________
_____________________________________________________________________________
What do you plan to tell your children about what
you are doing?___________________________
______________________________________________________________________________
______________________________________________________________________________
How do you feel about carrying twins or
triplets?________________________________________
______________________________________________________________________________
How do you feel about selective reduction to twins
if pregnancy results in more than two fetus?____
______________________________________________________________________________
How do you feel about aborting the pregnancy if it
is discovered that there is something seriously
wrong with the fetus?
____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I verify that the statements
made and information provided in this application are true, correct, and
complete. This application is executed
under penalty of perjury under of the laws of the State of Texas. My signature authorizes SPCT to run a
background check verifying the accuracy of this information.
_____________________________ ____/____/____
Signature Date
Include a picture of yourself and children.
Also include a copy of your drivers license.