Nicole Stryker, LCSW

LESLEE MURPHY, LCSW

PSYCHOSOCIAL ASSESSMENT Serving as Gestational Carrier/Partner

Demographic Information:

Name: ______Date: ______

Address:______

Phone: Home: ______Work: ______Cell: ______

Email Address: ______

DOB: ______Age: ______Race/Ethnicity: ______

Education ______

Occupation ______

Family History:

Name of Spouse/Partner: ______Age: _____

Years married or together:______Partner’s occupation: ______

Do you or your partner have any previous marriages? If so, please describe: _____

______

Please list any children, including names, ages and if from current or previous relationship: ______

______

Religious/Spiritual Traditions you practice: ______

Interests/Hobbies: ______

Reproductive History:

Physician Name: ______

Number of pregnancies ____ Number of live births ____ Number of miscarriages _____

Dates of previous pregnancies: ______

Please list any complications/losses:______

Lifestyle: Do you exercise regularly? If so, what do you do? ______

How would you describe your diet? ______

How well do you sleep? ______

What are your current stressors? ______

What do you do to comfort yourself? ______

Do you enjoy any hobbies?______

What do you do for fun? ______

Coping

Whom can you depend on for support? ______

Are you close with your family? ______

Have you or your spouse/partner previously sought counseling? ______

If so, please explain: ______

Are you or your spouse/partner currently taking or previously taken medication for depression or anxiety? _____ If so, please explain: ______

______

Serving as a Gestational Carrier:

Are you working with an agency or clinic: ______

What has motivated you to serve as an a carrier at this time? ______

______

Whom have you told about the possibility of serving as a carrier? ______

______

How did they respond? ______

Whom do you plan to tell? ______

Do you feel that your religion or culture has influenced your decision in any way?______

If so, please explain: ______How do you feel about being identified as the carrier ? ______

______

What are your thoughts about this? ______

Known Gestational Carrier:

If the intended parent is a friend or family member, please complete the following:

Name of Intended Parent? ______

Relationship to him/her? ______How long have you known him/her?______

Describe your relationship with the intended parent’s partner? ______

______

How will serving as a carrier change or affect the relationship with the intended parent?_____

______

Concerns/Questions you would like to address: ______

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