Become a Surrogate Mother Complete the form below to move to the next step and get access to information about the surrogacy process. Surrogate intake form-direct Step 1 of 4 25% Name* First Last Email* Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age*Height*Weight*Occupation*Do you have any plans to move out of the state?* No Yes When and where do you think you'll be moving to?*What city do you live in?*Marital Status* Single In a relationship but not living together Living with a partner Engaged Married Separated Divorced Widowed Spouse / Partner's full name* First Last Do you speak and understand English?* Yes No Some What is your main language?* What type of birth control are you currently using?* Abstinence Condoms Tubal ligation Vasectomy Birth control pills IUD without hormones IUD with hormones Implant Depo-Prevera shot Nuva Ring Cervical cap or diaphragm Withdrawal or rhythm method Other Other - what type of birth control?*Date of most recent delivery*Are you currently breastfeeding?* Yes No When do you anticipate weaning your child?*How many pregnancies have you had?* 0 1 2 3 4 5 6 or more How many children have you given birth to?* 0 1 2 3 4 5 6 or more Of the children you have given birth to, how many currently live in your home?* 0 1 2 3 4 5 6 or more How many miscarriages have you had?* 0 1 2 3 or more Please provide approximate dates of miscarriage(s) and any details that might be relevant*How many abortions have you had?* 0 1 2 3 or more Please provide approximate year(s) of abortion*Please check all conditions you have experienced during any of your previous pregnancies or deliveries*Check all that apply Cesarean section Premature birth (4 weeks early or more) Pre-eclampsia (high blood pressure) Gestational diabetes Postpartum depression Placenta previa Placenta abruption Bed rest Home monitoring Pre-term labor Other - anything exceptional about any of your pregnancies or deliveries No problems Which pregnancy did you need bed rest for and what duration?How long did you experience post partum depression and what treatment did you receive?How many cesarean sections have you had?* 1 2 3 4 or more Please explain. Provide as much information as possible such as which pregnancy, level of severity and any details that might be relevant.* Do you have any current medical problems?* Yes No Please explain your current medical problems*Do you take any prescription and/or non prescription medications?* Yes No What medications are you taking?*Do either you or your partner have a criminal past with any arrests?*This does not necessarily prevent you from becoming a surrogate, but we do need to know about it right up front. Yes No Please explain:*Provide any pertinent information such as dates, conviction, any probation, etc. Do you have a history with previous drug use? Alcohol abuse? Or treatment?* Yes No Please explain your drug or alcohol history and any treatment.*Are you receiving any government assistance? Please check all that apply* Food assistance Health care assistance Housing assistance Utility assistance Child care subsidy Welfare, cash aid or supplemental income Other I am not receiving any government assistance Other - what type of assistance?*Are you a smoker? (Including the use of E-Cigarettes)* I currently smoke regularly I currently smoke socially I used to smoke I've never been a smoker When did you stop smoking?*Does anyone in your household smoke?* Yes Yes, but not inside the home No Do you have health insurance?*Health insurance is not a requirement Yes No What is the name of your insurance?*Have you been a surrogate, or have you met with an agency in the past?* Yes No Please provide the details of past surrogacy history, or efforts at becoming a surrogate*Please confirm:* The information I have provided is correct to the best of my knowledge One final question... Would you like our surrogate coordinator to contact you by phone to answer any questions or discuss your options?* Yes please! No thank you, not necessary No opinion Comments or Questions? Is there anything else you would like us to know? Or do you have any questions you would like for us to address? Δ
