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Application for Intended Parents

"*" indicates required fields

Applicant Info

IP = Intended Parent
IP 1*
Please type your legal name. All legal documents will reflect your name as indicated below.

IP 2*
Please type your legal name. All legal documents will reflect your name as indicated below.

Contact Info

Address*

Date of Birth IP 1*
Are you a citizen of the United States IP 1*
If no, are you a legal permanent resident IP 1*

Date of Birth IP 2*
Are you a citizen of the United States IP 2*
If no, are you a legal permanent resident IP 2*

Have you or your spouse ever been charged with child abuse allegations?*
Have you or your spouse ever been convicted of a felony?*

Surrogacy Program/Clinic

Contact at Surrogacy Program
Is Surrogacy Program licensed in New York?
Contact at IVF Program*
Have you completed a medical evaluation IP 1*
Have you completed a mental health evaluation IP 1*
Have you completed a medical evaluation IP 2*
Have you completed a mental health evaluation IP 2*

Children

Do you have children?*

Employment

Are you currently employed IP 1*
Are you currently employed IP 2*

Embryo Formation

Sperm From:
Egg From:*
List name(s) here
Attorney's Address*
Do you have insurance?

Intended Parents

Is the Gestational Carrier known to you?*

Required Documents /Information

Please have the following documents ready to submit:
  • Medical Insurance Review
  • Last Will & Testament (addressing disposition of unused embryos and guardianship of children)
  • Health Care Proxy/Durable Power of Attorney Life Insurance
  • Supplemental InsurancePolicy/Health
  • Supplemental Insurance Policy/Loss of Reproductive Organs
  • Supplemental Insurance Policy/Disability Insurance
Name of Estate Attorney drafting ancillary documents
Name of Contact*

Signatures

Consent IP 1*
Consent IP 2*
Date*
This field is for validation purposes and should be left unchanged.

Attorney Advertisement: The hiring of a lawyer and the contemplation of collaborative reproduction and adoption are significant matters that should not be based solely on advertisements, editorials and/or other social media communication such as websites and blogs. This website pertains to general information regarding collaborative or third-party reproduction and adoption and is not intended as legal advice nor does it imply an attorney/client relationship with Law Offices of Laurie B. Goldheim; the contents herein should not be relied upon without professional counsel. The Law Offices of Laurie B. Goldheim does not necessarily endorse, and is not responsible for, any third-party content that may be accessed through this website and expressly disclaims all liability in respect to actions taken or not taken based on any or all of the content of this website.

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