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SURROGATE APPLICATION

Personal information

Address

Contact information

Others

Are you able to attend all local appointments?
Are you actively parenting at least one of your own children?
How soon would you like to begin your Surrogacy journey?
Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?)
Are there any other people residing in your home other than your children? or your partner?
Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed?
Do you have an existing health insurance policy?

Background

Do you drink alcoholic beverages?
Have you or your partner ever been investigated by governmental child protective agency?
Do you or your partner currently have any legal cases or claims pending?
Have you or your partner ever been involved in any lawsuit?
Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)?
Are you exposed to any second-hand smoke at home or at work?
Have you or your partner ever been arrested (including DUI arrests)

Medical/Reproductive History

Have you ever been a surrogate or egg donor before?
Are all of your children living with you currently?
Do you have legal custody of your children?
Do you plan on having more children of your own?
Do you have a regular menstrual cycle?
Do you have any past or current medical issues?
Are you allergic to any medication?
Have you ever been prescribed any medications in the last 5 years?
Have you had any surgeries?
Have you ever been diagnosed with :
Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected)
Have you had any abortions?

Pregnancy #1

Was this pregnancy for yourself or a surrogacy journey?
Any complications?
Vaginal or C-section?

Pregnancy #2

Was this pregnancy for yourself or a surrogacy journey?
Any complications?
Vaginal or C-section?
Have you or your partner if applicable ever had psychological counseling?
Have you ever been prescribed any psychiatric medications (including anti-depressants and anti-anxiety medications)?
Have you ever been diagnosed with any of the following?
Have you ever been hospitalized for psychiatric care?
Have you ever attempted suicide?

Surrogacy Questions

Would you be comfortable with the IP's in the delivery room?
Would you be willing to pump after delivery?
Are you comfortable having the IP in the transfer room/or recording the transfer for the IP?
Are you comfortable with injections and taking oral medication for surrogacy?

About you

Can you send us a few pictures of you?

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I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief.

Your application was successfully submitted. We will be in touch with you shortly, Thank you!

Psychological History

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