LESLEE MURPHY, LCSW
920 Frostwood, Suite 670
Houston, TX 77024
PSYCHOSOCIAL ASSESSMENT FORM
DONOR GAMETE PROGRAM
Demographic Information:
Name: ______Date: ______
Address:______
Phone: Home: ______Work: ______Cell: ______
Email Address: ______
DOB: ______Age: ______Race/Ethnicity: ______
Education ______
Occupation ______
Family History:
Name of Spouse/Partner: ______Age: _____
Years married or together:______Partner’s occupation: ______
Do you or your partner have any previous marriages? If so, please describe: _____
______
Please list any children, including names, ages and if from current or previous relationship:
______
______
Religious/Spiritual Traditions you practice: ______
Interests/Hobbies: ______
Reproductive History:
Physician Name: ______
Current diagnosis: (i.e. Male Factor, PCOS, etc.) ______
Date of initial diagnosis: ______Duration of treatment: ______
Previous fertility treatments (i.e. medication, IUI, IVF, etc.): ______
______
Number of pregnancies ____ Number of live births ____ Number of miscarriages _____
Dates of recent losses:______
Previous Surgeries: ______
Lifestyle:
Do you exercise regularly? If so, what do you do? ______
How would you describe your diet? ______
How well do you sleep? ______
What are your current stressors? ______
What do you do to comfort yourself? ______
Do you enjoy any hobbies?______
What do you do for fun? ______
COPING
What has been the most difficult aspect of dealing with infertility? ______
______
Has your fertility treatment affected other aspects in your life:
Relationships: ______
Career: ______
Intimacy/Sexual Relations: ______
Whom can you depend on for support? ______
Are you close with your family? ______
Have you or your spouse/partner previously sought counseling? ______
If so, please explain: ______
Are you or your spouse/partner currently taking or previously taken medication for
depression or anxiety? _____ If so, please explain: ______
______
Donor Egg/Sperm Treatment:
When was donor treatment first introduced?______By whom? ______
Why did you choose egg/sperm donation as treatment at this time? ______
______
Whom have you told about egg/sperm donor treatment? ______
How did they respond? ______
Whom do you plan to tell? ______
What do you plan to tell your child about his/her donor conception? ______
______
Do you feel that your religion or culture has influenced your decision in any way?______
If so, please explain: ______
Would you prefer a known or anonymous donor? ______Why: ______
______
If using an anonymous donor, what attributes will you look for? ______
______
Known Donor
If the donor is known please complete the following
Name of know Donor? ______
Relationship to her/him? ______How long have you known her/him? ______
What qualities does the donor possess which attracted you to her/him? ______
______
Describe your relationship with your donor’s spouse/partner? ______
______
How does your donor feel about being identified some day as the child’s donor? ______
______
What are your thoughts about this? ______