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Apply as a Surrogate
Basic
Information
Personal
History
Medical
Pregnancy
Personality
Images
Basic Questions
What is your BMI?
Calculate your BMI here
1 - 17
18 - 30
31 and above
Do you smoke?
Yes
No
Do you do drugs?
Yes
No
How old are you?
16 - 20
21 - 42
42 or older
How many children have you given birth to?
No children
1 or more
Are you on any of the following birth control medications: Mirena IUD, Depo Shot, Implanon?
Yes
No
Have you ever been diagnosed with bi-polar, schizophrenia, or clinical depression?
Yes
No
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Contact Info
First Name:
Last Name:
Email:
Primary Phone:
Secondary Phone:
Address
Address:
City
State
Zip code
Personal Information
Age
Height
Date of Birth
Weight
Race / Ethnicity
Religious Affiliation:
None
Christian
Catholic
Jewish
Buddhist
Muslim
Qwansa
Baptist
Methodist
Pentacostal
Hindu
Other
Current relationship status
Married
Single
Boyfriend
Engaged
Separated
Divorced
Highest educational achieved
Area of study
Are you currently employed?
Yes
No
Current occupation
Other Information
How many children do you have?
Have you ever placed a child for adoption?
Yes
No
Who lives with you in your home?
Are you receiving government assistance of any kind (incl. MediCare, etc)?
Yes
No
Please describe what kind and if you are planning on staying on assistance for the next year.
Are you a US Citizen or permanent resident?
Yes
No
Do you have a valid driver's license?
Yes
No
Do you have a reliable vehicle?
Yes
No
Do you have valid auto insurance?
Yes
No
Do you have a flexible work schedule?
Yes
No
Where did you hear about us?
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Personal Health history
Do you smoke cigarettes (You will need to quit 6 months prior to testing in order for nicotine not to show in your blood-work)?
Yes
No
Does anyone in your home, or anyone who frequently visits your home, smoke cigarrettes?
Yes
No
Do they smoke inside the house?
Yes
No
How many alcoholic beverages do you drink?
I don’t drink alcohol
I drink 3 or less alcoholic beverages per week
I drink 4 or more alcoholic beverages per week
Do you use drugs (you will be tested for both legal and illegal drugs)?
Yes
No
Does anyone in your home, or anyone who frequently visits your home, use drugs, including Marijuana (legal or illegally)?
Yes
No
Have you attended any function in the past 60 days where illicit drug use was going on (If yes, please explain)?
Yes
No
For surrogacy you must be willing to take self-injectable medications and/or suppositories for up to 14 weeks. Are you willing to take the required medications? (you can
read more about the medications here
)
Yes
No
What is your diet like? Please select all that apply:
Well Balanced
Vegan
Vegetarian
High Protein
High Sugar
High Fat
You and your partner would both be needed to be medically tested for sexually transmitted diseases. Will you both be willing to undergo medical and pshychological testing?
Yes
No
There will be a period of time where you will need to be sexually abstinent. Are you and your partner willing to refrain from sexual intercourse for up to three months if needed?
Yes
No
If you do not become pregnant on the first attempt, would you be willing to try again?
Yes
No
If employed, does your employer provide health insurance?
Yes
No
If not, do you have health insurance?
Yes
No
If so, what is the name of the insurance company?
Have you spoken to your family about your decision to become a surrogate?
Yes
No
How would you react if you were criticized for being a surrogate?
Why do you want to become a surrogate?
Are you willing to carry twins?
Yes
No
Only if a single embryo splits
It depends on the situation
Sometimes the physician will recommend selective reduction where you will eliminate a fetus or fetuses in order to eliminate risk to you and the remaining baby or babies. The Intended Parents will choose the best option for their family in this situation. Are you willing to undergo a selective reduction procedure if the intended parents feel it is best for their future family?
Yes
No
Are you willing to reduce from twins to singleton?
Yes
No
It is very rare that an OB will require an amniocentesis or a CVS procedure unless it is an imperative situation; however, in the case of an urgent situation when an intended parent is advised that this would be the best option for their baby, are you okay allowing the physician to make this recommendation?
Yes, if it is doctor recommended
No, never
In very rare cases a physician or intended parents may choose to terminate a pregnancy for your safety, a genetic abnormality, something wrong with the fetus, etc. Our agency believes these decisions should be the choice of the intended parents and what is best for their family. Are you okay allowing the intended parents this choice?
Yes
No
Maybe
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Family Life
Do you or anyone who lives in your home have a criminal record?
Yes
No
If yes, please explain the circumstances:
Are you and your partner willing to go through a background check?
Yes
No
What do you plan on doing with the surrogacy compensation?
Explain your occupation:
Do you have to do any heavy lifting/strenuous activity or are you exposed to any toxic or harsh chemicals?
Yes
No
When was your last tattoo?
When was your last piercing?
Where were you born?
Gifted Journeys believes that LOVE makes a family. We have a safe, judgement free agency that supports all types of intended parents who have the financial and emotional means to raise a child(ren). Which type of families are you willing to work with? Check all that apply:
Local Intended Parents?
Intended Parents out of State? (pregnancy and birth will still take place in your home state)
Intended Parents living internationally? (pregnancy and birth will still take place in your home state)
Intended Parents with children already?
Bi-Racial Intended Parents?
Gay Intended Parents?
Lesbian Intended Parents?
Single Heterosexual Male?
Single Heterosexual Female?
Single Gay Male?
Single Lesbian Female?
Hep B Positive parent? (if surrogate has already been vaccinated for Hep B or gets the vaccination, the infection cannot be passed along)
Need more information
An H.I.V. positive Parent (
read more
)
Need more information
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What form of birth control are you using?
Tubal Ligation
Vasectomy
Condoms
IUD
Mirena IUD
Diaphram
Patch
Pill
100% Abstinence
Depo-Provera
Norplant
Essure
When was your last Pap smear?
Was it normal?
Yes
No
If abnormal, what happened?
Have you ever had an abnormal Pap?
Yes
No
If over 40, when was your last mammogram?
What was the result?
Do you have a family history of cancer?
Yes
No
If so, explain.
Have you had any history of physical and/or sexual abuse?
Yes
No
If so, explain.
How many times have you been pregnant?
How many abortions?
How many miscarriages?
0
1
2+
If 1 or more, what caused the miscarriage?
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1st Pregnancy:
Date of Delivery:
How many weeks were you pregnant?
Gender
Male
Female
Delivery
Vaginal
C-Section
Complications
Baby weight
Current Relationship to Father
2nd Pregnancy:
Date of Delivery:
How many weeks were you pregnant?
Gender
Male
Female
Delivery
Vaginal
C-Section
Complications
Baby weight
Current Relationship to Father
3rd Pregnancy:
Date of Delivery:
How many weeks were you pregnant?
Gender
Male
Female
Delivery
Vaginal
C-Section
Complications
Baby weight
Current Relationship to Father
4th Pregnancy:
Date of Delivery:
How many weeks were you pregnant?
Gender
Male
Female
Delivery
Vaginal
C-Section
Complications
Baby weight
Current Relationship to Father
General:
Please let us know if you had trouble conceiving or any physician-ordered bed rest and explain any early deliveries?
Did you enjoy your pregnancy(ies), or were they difficult for you? What are you looking forward to most about being pregnant again? What are you scared or concerned about?
Are you currently taking any medications other than birth control?
Yes
No
Have you ever been diagnosed with any type of psychological disorder such as bi-polar disorder, PSD, etc.?
Yes
No
Are you on any medication for this or any other psychological disorder?
Yes
No
If yes, what medication are you taking?
Have you failed IVF transfers?
Yes
No
Are you willing to sign a medical release in order for our office to obtain your medical records?
Yes
No
Are you taking any vitamins or supplements?
Yes
No
If yes, what vitamins or supplements are you taking?
Have you ever been vaccinated?
Yes
No
Can you provide the records?
Yes
No
Are your children vaccinated?
Yes
No
Can you provide the records?
Yes
No
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What is your favorite childhood memory?
What would your kids say is their favorite thing to do with you?
What is your greatest wish for your own child(ren)?
What is the funniest thing your child(ren) have ever done?
What would you tell your intended parents is the best thing about being a parent?
What message would you like to pass along to the child(ren) to whom you would be the surrogate?
If you could only teach your child one lesson in life, what would it be?
If you could choose one person to be the role model for your child(ren), who would it be? Why?
How would your friends describe you?
How would your kids describe you?
Tell us about your child(ren)?
Decribe a perfect day with your family.
(If applicable) How would you describe your partner/husband?
(If applicable) How does your partner/husband feel about you becoming a surrogate?
How do your extended family members and close friends feel about you becoming a surrogate?
If you could invite 3 people to a dinner party (alive or passed), who would they be?
What is your favorite movie?
What is your favorite color?
How do you feel about animals? Do you have any?
What books do you like to read?
How long have you been thinking about becoming a surrogate?
What would you like to do with the money you make for your time and efforts involved in surrogacy?
What type of relationship would you prefer to have with your intended parents?
What is your religious affiliation (or beliefs), if any?
Are you open and willing to eat a healthful diet during your surrogacy?
What do you feel about your personality would make you a good surrogate?
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