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Are you currently in any kind of relationship?
(Married, Dating, Domestic Partnership, Civil Union, Separated, Widowed, etc.)
Partner's First Name
Please provide details on your branch, rank and current status.
(Enlisted, active duty, National Guard, reserve, etc.)
Please provide details on their relation to you, their branch, rank and current status.
Please list all of your previous pregnancies and deliveries (include miscarriages or abortions).
If possible, please also list the dates of all deliveries (month and year), weeks gestation at delivery, birth sex, birth weights, and relationship of all children to whom you have given birth.
Please list the name, city and state of all hospitals you have delivered at, as well as the delivering OBGYN (if known).
If you had an assisted home birth or used a birthing center, please list who we can request delivery records from. Please also list dates of care (just the year is OK):
Do you have legal and physical custody of all of your children?
Joint custody is OK for this question.
What was the date of your most recent surrogacy delivery?
Have you ever taken medications for a behavioral or mental health condition?
(Examples include antidepressants or anxiety medications such as Prozac, Zoloft, Lexapro, Celexa, Paxil, Luvox, Cymbalta, Effexor, Wellbutrin, or medications for ADHD such as Adderall, Vyvanse, Ritalin, or Strattera.)
Would you agree to receive the following vaccinations during pregnancy if recommended by an OB?
Please check all that apply.
Have you experienced any of the following?
*Please mark all that apply. Please note that some of these conditions may disqualify a candidate but warrant further discussion.
Have you ever been referred by your OB/GYN to a specialist?
(i.e. fertility doctor or maternal/fetal “high risk” OB)
Have you ever been advised not to become pregnant?
(i.e. too risky, too soon after another pregnancy, etc.)
Provide month and year:
(Many clinics recommend at least a year after certain cosmetic procedures before starting medications)
Are you or any of your household family members on any form of government assistance?
(WIC, Medicaid, Food Stamps, SNAP, etc.)
Please list their name(s), age(s), email address(es), and their relation to you.
All adults age 18+ living in your home must have a criminal background check performed in order for you to be approved as a surrogate.
Do you, or have you ever smoked/vaped?
(Tobacco or THC products)
Have you ever used recreational drugs?
(This includes edibles and food containing marijuana/TCH)
What type, and how severe was your illness?
(On a scale of 1 = mild to 10 = severe.)
Have you ever been under the care of a psychiatrist or psychologist?
(Hospitalization, medication, on-going therapy, etc.)
Please explain:
Please explain your household member's accusation, charge, arrest, and/or conviction:
You understand that in order to become a surrogate, you and all 18+ members of your household will need to consent to a background check.
Please select YES to agree.
Are you comfortable with the various medications required of the surrogacy process, including daily injections for extended periods of time?
We will provide you with full details on these medications and the process during our one-on-one meeting.
Are you willing to travel for medical procedures related to your surrogacy?
We sometimes offer to match with intended parents residing in other states. Any expenses incurred from traveling to appointments at their clinic will be paid for by the intended parents.
Please describe your ideal Intended Parents for a surrogacy journey.
Include type of person/couple, age(s), area in which they reside, personality, values or philosophies, number of babies you would prefer to carry, and any other relevant details.
This is not binding, but it allows us to understand your initial preferences as we begin to connect and determine the right fit for your journey.
