Surrogacy Psychological Assessment Form
Screening form to evaluate emotional readiness, support system, coping, expectations, and concerns related to surrogacy.
Applicant Background
Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Email
*
example@example.com
Role in the Surrogacy Process
*
Intended Parent
Surrogate
Partner/Spouse
Other
Current Age Range
*
18-24
25-29
30-34
35-39
40-44
45+
Psychological Readiness Assessment
What is your motivation for pursuing surrogacy?
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Rate your understanding and readiness for the surrogacy process.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I understand the medical steps involved.
1
2
3
4
5
I understand the legal and emotional aspects of the arrangement.
6
7
8
9
10
I feel able to manage stress during the process.
11
12
13
14
15
My current mood and emotional well-being feel stable.
16
17
18
19
20
My expectations about the arrangement are realistic.
21
22
23
24
25
Overall, how emotionally prepared do you feel for surrogacy?
*
1
2
3
4
5
Support and Experience Review
Support System Availability
*
Rows
Available
Limited
Not Available
Partner/Spouse
26
27
28
Family Members
29
30
31
Close Friends
32
33
34
Community or Faith Support
35
36
37
Other Support
38
39
40
Prior Experience and Support Resources
*
Rows
Yes
No
Prefer Not to Say
Experienced fertility-related situations
41
42
43
Experienced pregnancy-related situations
44
45
46
Experienced surrogacy-related situations
47
48
49
Currently receiving counseling or therapy
50
51
52
Would be open to counseling or therapy support
53
54
55
Current Concerns Affecting Participation
Submit Assessment
Should be Empty: