Intake Form: Birth and Infertility

When you have decided to use artificial conception to have a child, certain legal concerns may have to be addressed. You should therefore seek the assistance of an experienced attorney. The attorney will require certain information from you to be able to assist you. Use this form to provide the attorney with the needed information. Complete this form before you meet the attorney for the first time and hand it over to him or her at the meeting.

 

Prospective MotherProspective Father
Name
Age
Social Security Number
Address
Time at the address in years and months
Previous addresses in the last 10 years
Telephone NumberWork

Home

Email
Fax
Employment Position
Employer Name
Employer Address
Time with employer in years and months
Previous employers in the last 10 years
Gross Income
Source and amount of Income
Health/Medical History (list known illnesses)
Arrests, if any (list details)
Alcohol or drug abuse
Previous Marriages if any
Previous MarriagesName of Spouse

Duration

Ended by

Children from other marriagesName

Age

Born/Adopted

Living With

Date of Marriage

 

Place of Marriage

 

Child From the Marriage

NameAgeBorn/AdoptedLiving With

 

 

Check the procedures that you are interested in

 

Assisted Reproductive Technology _____    Donor Sperm _____    Donor Eggs _____

 

Gestational Surrogacy  _____

 

Surrogacy Using Prospective Father’s Sperm and Donated Eggs _____

 

Surrogacy Using Prospective Father’s Sperm and Surrogate’s Eggs _____

 

Surrogacy Using Donated Sperm and Donated Eggs _____

 

 

Are you looking for anything specific in the donor:

 

Physical characteristics/Race or ethnicity ____________________________________________

 

______________________________________________________________________________

 

Age (please provide a range): _____________________________________________

 

Health considerations: ___________________________________________________________

 

______________________________________________________________________________

Mental or emotional requirements: _________________________________________________

 

______________________________________________________________________________

 

Location: _____________________________________________________________________

 

Degree of involvement you wish to have in the pregnancy:

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

_____ Attend prenatal care appointments

 

_____ Surrogate to live in your home till birth or some time

 

_____ Present at the birth

 

Funds available

 

Up to $1,000 _____   $1,000 to $5,000 _____   $5,000 to $10,000 _____

 

$10,000 to $20,000 _____   $20,000 to $30,000 _____   Over $30,000 _____

 

% of expenses covered by insurance________

 

 

Do you have a completed home study?   Yes _____   No _____

 

Have you ever been denied an adoption?   Yes _____   No _____

 

References

 

NameAddressKnown SinceRelation

 

Other Important Information:

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Questions for the Attorney:

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

_______

Would you like to discuss your legal matter?

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Our receptionist will assist in scheduling new and existing clients for all offices. For initial consultations we will ask you a few questions and then find the best time for you to talk to one of the lawyers that best fits your legal matter.

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The Law Offices of Tom Hogan will provide you with personalized attention and guidance. Protecting your rights is our main objective. We have been representing clients for the past 30 years and our experienced team of attorneys will advise you of the legal consequences of every decision you take.