Client Intake Form

Are you:
SurrogateIntended Parent (required)

Your email address (required)

Details of the Parties:

INTENDED PARENT 1
Full Name (including middle names) (required)
Pronouns (she/he/they):
Date of Birth (required)
Occupation
Address (required)
Email (required)
Phone Number (required)

INTENDED PARENT 2
Full Name (including middle names)
Pronouns (she/he/they):
Date of Birth
Occupation

Intended Parents Relationship Commencement Date

Marriage Date (if applicable)

SURROGATE
Full Name (including middle names) (required)
Pronouns (she/he/they):
Date of Birth (required)
Occupation
Address (required)
Email (required)
Phone Number (required)

SURROGATE'S PARTNER (including middle names) (if applicable)
Full Name
Pronouns (she/he/they):
Date of Birth
Occupation

Surrogate and Partner Relationship Commencement Date

Marriage Date (if applicable)

How do the Parties know each other?

DONORS (IF APPLICABLE) - ARE ANY EGG, SPERM OR EMBRYO DONORS INVOLVED?
Names and dates of birth

OTHER PARTY'S LAWYER (IF KNOWN)

CHILDREN - OF THE SURROGATE, AND OF THE INTENDED PARENTS
Full Names and dates of birth

FERTILITY SPECIALIST & CLINIC

CLINIC COUNSELLOR NAME (if applicable)

INDEPENDENT PSYCHOLOGIST NAME (if applicable)

Have you commenced counselling?
YesNo

Any Additional Comments

Do you need Sarah to draft the Agreement? YesNo

If the Agreement has been drafted, please email a copy to sarah@sarahjefford.com

How did you hear about Sarah?