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Gestational Carrier Questionnaire
We encourage you to provide us with accurate and thorough responses so that we can match you with the best potential parents.
Contact Information
Date
*
-
Month
-
Day
Year
Date Picker Icon
Relationship Status
Married
Single
Divorced
In a relationship
Separated
Engaged
Domestic Partnership
Widowed
Name
*
First Name
Last Name
Age
*
Date of Birth
*
Phone Number
-
Area Code
Phone Number
Spouse/Partner Name
First Name
Last Name
Age
Partner's Date of Birth
Phone Number
*
-
Area Code
Phone Number
Email
*
Alt Phone Number
-
Area Code
Phone Number
Alt Email
Skype address
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
How long have you lived at this location?
*
Total Household Income
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Contact Preferences
Best time of day to reach you?
*
Best way to reach you?
*
Email
Text
Phone call
Special instructions for emailing and calling:
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Personal Information
Gestational Carrier
Where were you born?
*
How many siblings do you have?
*
Are you the:
*
Youngest
Middle
Oldest
Only
Are your parents living?
*
Yes
No
Other
Are you close to your family? Please describe your relationship:
*
Current occupation/position:
*
Personal salary range
*
Please Select
0-30,000
31,000-50,000
51,000+
Please list any degrees, licenses, certificates or areas of training that you have.
Have you ever been, or are you currently in the military?
*
Yes
No
If yes, Thank you for your service. Please specify and list dates:
How many children do you have?
*
Do you have legal custody of your biological children?
*
Yes
No
Do you have children other than those you have given birth to?
*
Yes
No
Shared custody
Please explain:
Have you been denied acceptance into an adoption, surrogacy, or egg donation program
*
Yes
No
If yes, please explain:
Religious affiliation:
*
Sexual orientation:
*
What languages do you speak?
*
Do you have a criminal record of any kind or been convicted of a felony?
*
Yes
No
If yes, please explain:
Do you drink alcohol? (keep in mind - this is while you're not pregnant)
*
Yes
No
If yes, how often?
1-2 drinks a week
3-5 drinks a week
Holidays
Social gatherings
Infrequently
Do you use nicotine (smoke, vape, etc)?
*
Yes
No
Vape
Cigarette
If yes, do you understand you will need to abstain for a minimum of 6 months before acceptance into the program?
I agree to abstain nicotine use for a minimum of 6 months prior to Surrogate program acceptance and throughout entire surrogate journey.
No
Do you use marijuana (smoke, vape, edibles, etc)?
*
No
Smoke
Vape
Edible
Medically
Socially
Daily
1-2 times a week
3-5 times a week
Infrequently
If yes, do you understand you will need to abstain for a minimum of 6 months before acceptance into the program?
Not Applicable
I agree to abstain marijuana/THC use for a minimum of 6 months prior to Surrogate program acceptance and throughout entire surrogate journey.
No
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Spouse/Partner
Where were you born?
How many siblings do you have?
Are you the:
Youngest
Middle
Oldest
Only
Are your parents still living?
Yes
No
Father?
Yes
No
Are you close to your family? Please describe your relationship:
Current occupation/position:
Please list any degrees, licenses, certificates or areas of training that you hold.
Have you ever been, or are you currently in the military?
Yes
No
If yes, thank you for your service. Please specify and list dates:
Religious affiliation:
What languages do you speak?
Do you have a criminal record of any kind or been convicted of a felony?
Yes
No
If yes, please explain:
Do you drink alcohol?
Yes
No
If yes, how often?
Do you use nicotine?
Yes
No
Smoke
Vape
Other
Do you use illegal drugs?
Yes
No
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Medical/ Insurance Info
Gestational Carrier
Do you have health insurance
*
Yes
No
If yes, is your insurance surrogate friendly?
Yes
No
In review
Unsure
What is your annual Max Out of Pocket insurance cost?
If yes, does it cover maternity?
Yes
No
Who is your health insurance provider?
Do you have a preferred OB?
*
Do you have Life Insurance?
*
Yes
No
If yes, what is your coverage?
Do you have a Short term disability policy?
*
Yes
No
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Gestational Carrier
Current birth control method
*
When was your last PAP and/or Wellness check (Month/Year)?
*
Did you need the assistance of an infertility clinic/or reproductive endocrinologist to become pregnant?
*
Yes
No
Please explain
Have you been a Surrogate before?
Yes
No
Birth Info
*
Gender
Birth date
Weight
Vaginal/C-section
Weeks of Gestation
Complications
Child
Child
Child
Child
Child
Child
Surrogacy Birth Info
*
Gender
Birth date
Weight
Vaginal/C-section
Weeks of Gestation
Complications
Child
Child
Child
Child
Child
Child
Please tell us about your pregnancy experience.
Have you ever had a miscarriage?
*
Yes
No
If yes, when? How far along were you in the pregnancy(ies)?
Have you been an egg donor?
*
Yes
No
Do you have any allergies?
*
Yes
No
If yes, please list:
Have you ever been hospitalized or had a major illness?
*
Yes
No
If yes, please explain:
Do you have any chronic medical conditions/problems?
*
Yes
No
If yes, please explain:
Have you ever suffered from severe depression?
*
Yes
No
Current/Treated
Situational/Resolved
Have you seen a psychiatrist, psychologist, or any other mental health professional?
*
Yes
No
If yes, please explain: (Medications, treatment, length of therapy, etc)
Have you ever been prescribed psychiatric medication(s)
*
Yes
No
If yes, please list dates and explain:
Do you have any sexually transmitted diseases?
Yes
No
Past/Resolved
Current/Treated
Please share any relevant details regarding your STD history.
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Spouse/Partner
Do you have any sexually transmitted diseases?
Yes
No
Past/Resolved
Current/Treated
If yes, please list dates and explain:
Do you have any chronic medical conditions/problems? If yes, please explain:
Have you ever suffered from severe depression? If yes, please explain:
Have you seen a psychiatrist, psychologist, or any other mental health professional? If yes, please list dates and explain:
Have you ever been prescribed psychiatric medication(s) If yes, please list dates and explain:
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Gestational Carrier
Personality and Relationship
Marital status
*
Married
Single
Divorced
Relationship
How did you meet?
*
How long have you been together?
*
Please describe your personality in as much detail as possible. What are your positive and negative qualities, values and beliefs?
*
What values resonate most with you?
*
What is your favorite?
Time of year
*
Holiday
*
Music
*
Entertainment
*
Vacation
*
Food
*
Please describe your spouse/partner in as much detail as possible. Tell us about his/her personality including positive and negative traits. What are your favorite characteristics about him/her?
What are your interests and hobbies?
*
Please describe your home and neighborhood?
*
Please describe your home life?
*
Have you ever lived in another country? Details:
*
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Spouse/Partner
Personality and Relationship
Please describe your personality in as much detail as possible. What are your positive and negative qualities, values and beliefs?
What values resonate to you most?
What is your favorite?
Time of year:
Holiday
Music
Entertainment:
Vacation:
Food:
Please describe your spouse/partner in as much detail as possible. Tell us about his/her personality, including positive and negative traits. What are your favorite characteristics about her?
What are your interests and hobbies?
Please describe your home life?
Have you ever lived in another country? Details:
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Surrogacy specific questions
Both Partners
Please describe your support system and any fears or concerns you have about becoming a surrogate:
*
How do you think you will feel, on an emotional level, carrying someone else's baby/ies? Please address any concerns you have regarding this matter.
Have you discussed your plans to become parents via surrogacy with your family and friends?
*
Yes
No
What will you tell your children about your surrogacy?
*
Please describe the ideal parent or family you would like to help with surrogacy.
*
Are there any circumstances that you would NOT want to work with potential Parents? Please explain.
Do you plan on filming or taking pictures throughout the process?
Yes
No
How much contact would you like with your Intended Parents throughout the pregnancy? Are you willing to send them updates between doctor appointments via telephone and/or email? Would you be willing to occasionally send/email pictures of yourself and share details about the pregnancy? (Please be specific in describing what you have in mind, as we want to make sure you are matched accordingly.)
*
Please discuss the qualities you believe to be most important for Intended Parents
*
Letter to Intended Parents
*
Please write a letter to your future Intended Parents. Include your wishes for them. Share why you are choosing surrogacy and the hopes you have for your journey together.
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Is this the first time being a surrogate?
*
Yes
No
How long have you been considered being a surrogate?
*
How many attempts will you be willing to undergo to conceive a child?
*
2-3 is average
If no, please tell us about your surrogacy experience in as much detail as possible. Include dates
What was your relationship like with your former Intended Parents through out the pregnancy?
Please explain your current relationship you have with your former Intended Parents:
Did you undergo a reduction or amniocentesis?
If yes, please explain the circumstances.
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Are you interested in having the Intending Parents attend doctor appointments/ultrasound appointments with you? (Both reproductive endocrinologist and OB)
*
Yes
No
Are you willing to undergo an amniocentesis if requested by IPs or OB?
*
Yes
No
Unsure
How much contact do you envision having with your Intended Parents after the pregnancy and delivery? Please be specific
*
Are you interested in pumping breast milk for your Intended Parents?
*
Yes
No
Do you think you will want to do a sibling project?
*
Yes
No
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The following questions are ones that you and your potential Intended Parents must agree upon. Please consider these questions carefully and answer with complete honesty. These issues are key in making sure we find IP's that will make an ideal match for you.
Have you shared with your family and friends that you are becoming a surrogate?
If yes, how did they respond? If no, why have you chosen not to share?
Oftentimes, the reproductive endocrinologist will transfer 1-2 embryos Because of this, it is possible that you could become pregnant with multiples (two or more babies). How would you feel about carrying twins?
*
How would you feel about carrying triplets?
*
If it is "medically indicated" endangering your health, or the fetus(es) would you be willing to reduce high order multiples (triplets or more)?
*
Yes
No
Please explain:
*
I understand that the intended parents will be the decision makers regarding any termination or reduction decisions.
*
Yes
No
If it is confirmed by a neonatal expert that the baby has a genetic condition, fetal abnormality, or a disease, that will have a long term detrimental impact, will you allow Intended Parents to make the decision of termination at any given time during the in the pregnancy
*
Yes
No
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Please discuss any additional information that you would like your potential Intended Parent to know about you:
Please submit your Application and Email a few photos that you would like to be used in your profile packet.
*
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Please read the below statements and sign/date stating that you agree:
By entering my/our name(s) below, I /we agree that the information provided in this questionnaire is accurate and true to the best of my/our knowledge.
Partner #1
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Signature
Partner #2
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Signature
Please click the "Submit My Application," button below If you would like a copy select "Print Form"
Abundant Life Surrogacy
2716 W Rose Hill St Boise, ID 83705 Abundantlifesurrogacy@gmail.com
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Submit
Print Form
By clicking Submit you will be redirected to a new page where you can provide your photos.
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