<p> LESLEE MURPHY, LCSW</p><p>PSYCHOSOCIAL ASSESSMENT Serving as Gestational Carrier/Partner</p><p>Demographic Information:</p><p>Name: ______Date: ______</p><p>Address:______</p><p>Phone: Home: ______Work: ______Cell: ______</p><p>Email Address: ______</p><p>DOB: ______Age: ______Race/Ethnicity: ______</p><p>Education ______</p><p>Occupation ______</p><p>Family History:</p><p>Name of Spouse/Partner: ______Age: _____</p><p>Years married or together:______Partner’s occupation: ______</p><p>Do you or your partner have any previous marriages? If so, please describe: _____ </p><p>______</p><p>Please list any children, including names, ages and if from current or previous relationship: ______</p><p>______</p><p>Religious/Spiritual Traditions you practice: ______</p><p>Interests/Hobbies: ______</p><p>Reproductive History:</p><p>Physician Name: ______</p><p>Number of pregnancies ____ Number of live births ____ Number of miscarriages _____</p><p>Dates of previous pregnancies: ______</p><p>Please list any complications/losses:______</p><p>Lifestyle: Do you exercise regularly? If so, what do you do? ______</p><p>How would you describe your diet? ______</p><p>How well do you sleep? ______</p><p>What are your current stressors? ______</p><p>What do you do to comfort yourself? ______</p><p>Do you enjoy any hobbies?______</p><p>What do you do for fun? ______</p><p>Coping</p><p>Whom can you depend on for support? ______</p><p>Are you close with your family? ______</p><p>Have you or your spouse/partner previously sought counseling? ______</p><p>If so, please explain: ______</p><p>Are you or your spouse/partner currently taking or previously taken medication for depression or anxiety? _____ If so, please explain: ______</p><p>______</p><p>______</p><p>Serving as a Gestational Carrier:</p><p>Are you working with an agency or clinic: ______</p><p>What has motivated you to serve as an a carrier at this time? ______</p><p>______</p><p>Whom have you told about the possibility of serving as a carrier? ______</p><p>______</p><p>How did they respond? ______</p><p>Whom do you plan to tell? ______</p><p>Do you feel that your religion or culture has influenced your decision in any way?______</p><p>If so, please explain: ______How do you feel about being identified as the carrier ? ______</p><p>______</p><p>What are your thoughts about this? ______</p><p>Known Gestational Carrier:</p><p>If the intended parent is a friend or family member, please complete the following:</p><p>Name of Intended Parent? ______</p><p>Relationship to him/her? ______How long have you known him/her?______</p><p>Describe your relationship with the intended parent’s partner? ______</p><p>______</p><p>How will serving as a carrier change or affect the relationship with the intended parent?_____</p><p>______</p><p>Concerns/Questions you would like to address: ______</p><p>______</p>