Autobiographical Questionnaire

Step 1 of 2

AUTOBIOGRAPHICAL QUESTIONNAIRE
These questions should have already been answered by the surrogate applicant. Her husband (or significant other if not married but living with someone) must now must fill out this form separately. Please try to answer the questions as completely and accurately as possible. The more you can tell us about yourself and your family, the better we will be able to evaluate you, and the better your chances will be of getting selected.
Name*
First Last
Your wife's (or significant other's) Name (Who is applying to become the surrogate)?*
Your Email Address*
1. Where were you born? How big a town was it? Did you grow up mainly in this town? If not, please give a history of the moves your family made including the dates and places where you moved. Also, please give a summary of your ethnic background.*
1. Where were you born? How big a town was it? Did you grow up mainly in this town? If not, please give a history of the moves your family made including the dates and places where you moved. Also, please give a summary of your ethnic background.
2. What memories of your childhood do you have? Are there any that are particularly painful or wonderful? Why?*
2. What memories of your childhood do you have? Are there any that are particularly painful or wonderful? Why?
3. What are your biological parents' names, ages, occupations, and marital status? If they are married, how long have they been married? If either has passed away, please state when and from what cause?*
3. What are your biological parents' names, ages, occupations, and marital status? If they are married, how long have they been married? If either has passed away, please state when and from what cause?
4. If they aren't married, when were they divorced? How did that affect you?*
4. If they aren't married, when were they divorced? How did that affect you?
5. Where do your parents live now? How often do you see them?*
5. Where do your parents live now? How often do you see them?
6. How well did you get along with them while you were growing up? How well do you get along with them now?*
6. How well did you get along with them while you were growing up? How well do you get along with them now?
7. Did your parents get along with each other? Did your family as a whole get along? If not, why not?*
7. Did your parents get along with each other? Did your family as a whole get along? If not, why not?
8. If your parents are divorced, have either remarried? If so, when?*
8. If your parents are divorced, have either remarried? If so, when?
9. If you have stepparents, what are their names, ages, and occupations?*
9. If you have stepparents, what are their names, ages, and occupations?
10. How well did you get along with either of them growing up? Where do they live now? How often do you see them?*
10. How well did you get along with either of them growing up? Where do they live now? How often do you see them?
11. How many brothers and/or sisters do you have? What are their names, ages, and occupations? Where do they live? Are they married? Children? How well did you get along with him/her growing up? If you have step-sisters or step-brothers, please answer these questions as they relate to them also.*
11. How many brothers and/or sisters do you have? What are their names, ages, and occupations? Where do they live? Are they married? Children? How well did you get along with him/her growing up? If you have step-sisters or step-brothers, please answer these questions as they relate to them also.
12. Is there anyone who has been particularly influential in your life? Tell me about them and how they have been important to you.*
12. Is there anyone who has been particularly influential in your life? Tell me about them and how they have been important to you.
13. When do you see your family members? Do you enjoy spending time with your parents/brothers/sisters? If not, why not?*
13. When do you see your family members? Do you enjoy spending time with your parents/brothers/sisters? If not, why not?
14. BECAUSE OF RECENT PROBLEMS WITH FAMILY MEMBERS OBJECTING TO SURROGACY, YOU ARE NOW REQUIRED TO DISCUSS YOUR PARTICIPATION IN THE PROGRAM WITH BOTH YOUR AND YOUR SPOUSE'S FAMILY. DO NOT SEND THIS APPLICATION BACK TO US UNTIL YOU HAVE DONE SO. What were the various people's reactions when you told them what you were doing?*
14. BECAUSE OF RECENT PROBLEMS WITH FAMILY MEMBERS OBJECTING TO SURROGACY, YOU ARE NOW REQUIRED TO DISCUSS YOUR PARTICIPATION IN THE PROGRAM WITH BOTH YOUR AND YOUR SPOUSE'S FAMILY. DO NOT SEND THIS APPLICATION BACK TO US UNTIL YOU HAVE DONE SO. What were the various people's reactions when you told them what you were doing?
15. What was your religious/spiritual upbringing? What do you think is the meaning of life? What do you see as your role in this world?*
15. What was your religious/spiritual upbringing? What do you think is the meaning of life? What do you see as your role in this world?
16. Do you attend church now? If so, which one? Does your spouse and/or children also attend?*
16. Do you attend church now? If so, which one? Does your spouse and/or children also attend?
17. Tell me about your high school experience. Did you enjoy it? Did you attend all your high school years at one school? If not, how many? What was your grade point average? Did you graduate? If so, when? If not, why not?*
17. Tell me about your high school experience. Did you enjoy it? Did you attend all your high school years at one school? If not, how many? What was your grade point average? Did you graduate? If so, when? If not, why not?
18. What kinds of extracurricular activity did you participate in?*
18. What kinds of extracurricular activity did you participate in?
19. Did you work while in high school? If so, what kinds of jobs did you have? How many hours did you work each week?*
19. Did you work while in high school? If so, what kinds of jobs did you have? How many hours did you work each week?
20. Did you date during high school? Frequently or one person for a long time?*
20. Did you date during high school? Frequently or one person for a long time?

21. Did you attend any type of school after high school? If so, where? Did you graduate? If not, why not? What was your grade point average? Did you enjoy your post-high school experience? Why or why not?*
21. Did you attend any type of school after high school? If so, where? Did you graduate? If not, why not? What was your grade point average? Did you enjoy your post-high school experience? Why or why not?
22. What kinds of extracurricular activity did you participate in?*
22. What kinds of extracurricular activity did you participate in?
23. Tell me about any jobs you've had since high school. What did you do, how many hours, why did you leave, etc.? What did you like or dislike about it?*
23. Tell me about any jobs you've had since high school. What did you do, how many hours, why did you leave, etc.? What did you like or dislike about it?
24. Did you date during college? Frequently or one person for a long time?*
24. Did you date during college? Frequently or one person for a long time?
25. If you are currently employed, tell me about your job. Do you see yourself staying at this position for a while? What do you want to achieve at your present job? If you are planning on leaving, why? What are your career goals?*
25. If you are currently employed, tell me about your job. Do you see yourself staying at this position for a while? What do you want to achieve at your present job? If you are planning on leaving, why? What are your career goals?
26. What have you achieved in life? Learned? Accomplished? What are you most proud of? What are you least proud of? Why?*
26. What have you achieved in life? Learned? Accomplished? What are you most proud of? What are you least proud of? Why?
27. Has there been any particular event or experience in your life that has had a significant effect on you? What happened?*
27. Has there been any particular event or experience in your life that has had a significant effect on you? What happened?
28. Tell me about your spouse or significant other. Where did you meet? What attracted you to him/her? How long did you date prior to living together/getting married?*
28. Tell me about your spouse or significant other. Where did you meet? What attracted you to him/her? How long did you date prior to living together/getting married?
29. If the relationship ended, tell me when and why. For any subsequent relationships you have had, please provide the same information as in question #28.*
29. If the relationship ended, tell me when and why. For any subsequent relationships you have had, please provide the same information as in question #28.
30. How many times has your significant other, wife,or wives been pregnant? How many were live births? Miscarriages? Abortions?*
30. How many times has your significant other, wife,or wives been pregnant? How many were live births? Miscarriages? Abortions?
31. How many children do you have? Tell me their names, ages, who their biological father is/are, and whether your child has any significant health problems or genetic diseases or deformities.*
31. How many children do you have? Tell me their names, ages, who their biological father is/are, and whether your child has any significant health problems or genetic diseases or deformities.
32. Tell me about your experience of being a parent. Do you enjoy it? How much time do you spend with your children? How do you spend time with them? What are your goals for your children?*
32. Tell me about your experience of being a parent. Do you enjoy it? How much time do you spend with your children? How do you spend time with them? What are your goals for your children?
33. Have you ever placed a child for adoption? If so, when and why? What was your emotional reaction to it? Have your feelings changed over the years?*
33. Have you ever placed a child for adoption? If so, when and why? What was your emotional reaction to it? Have your feelings changed over the years?
34. Have you ever lost anyone close to you? Who? How did you deal with your loss?*
34. Have you ever lost anyone close to you? Who? How did you deal with your loss?
35. Are you adopted? Do you know anyone who is? Do you think this has affected your decision to be a surrogate?*
35. Are you adopted? Do you know anyone who is? Do you think this has affected your decision to be a surrogate?
36. Do you know anyone who has had fertility problems? If so, please describe their difficulties.*
36. Do you know anyone who has had fertility problems? If so, please describe their difficulties.
37. Have you or your spouse ever been in counseling of any kind? If so, when and why? What was the outcome from your viewpoint?*
37. Have you or your spouse ever been in counseling of any kind? If so, when and why? What was the outcome from your viewpoint?
38. Other than minor traffic offenses, have you ever been arrested or convicted of any crime? If so, what offense, and when.*
38. Other than minor traffic offenses, have you ever been arrested or convicted of any crime? If so, what offense, and when.
39. What would you say is your best quality? Your worst? Your spouse’s best and worst qualities?*
39. What would you say is your best quality? Your worst? Your spouse’s best and worst qualities?
40. Is there anything else about you we should know that would assist us in evaluating your wife as a possible surrogate?*
40. Is there anything else about you we should know that would assist us in evaluating your wife as a possible surrogate?
Your Initials:*
Today's Date:*
Today's Date:
Phone
This field is for validation purposes and should be left unchanged.

“Last Online Step.”

Congratulations, you are almost done! Please have your husband or significant other complete the Autobiographical Questionnaire by following this link:

Click Here

You should have already answered these questions as part of your application, but your spouse/significant other needs to answer them too.

Your husband/partner should complete this portion immediately after you have finished the initial application.

Please try to answer the questions as completely and accurately as possible. The more you can tell us about yourself and your family, the better we will be able to evaluate you, and the better your chances will be of getting selected.

IF YOUR HUSBAND/PARTNER DOES NOT COMPLETE THIS FORM, YOUR APPLICATION WILL NOT BE CONSIDERED!

This is a secure form and 100% private. We will not use any of this information for any purpose other than to evaluate you as a surrogate mother.

This is a secure form and 100% private. We will not use any of this information for any other purpose than the required process to approve you as a surrogate mother.

If you are unable to download the application, please email us at scl@s954610285.onlinehome.us or give us a call at 1-888-SURROGATE, and we’ll be happy to assist you.

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