Please complete this bio questionnaire so we can finish building your surrogate profile.
Full Name
*
What is your email address?
*
What is your phone number?
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Religion
Highest Level of Education
If you are a Green Card Holder when does it expire?
Have you had a tattoo or piercing in the past 12 months?
Yes
No
Are you planning on getting a tattoo or piercing in the next 12 months?
Yes
No
Do you drink alcohol?
Yes
No
If so, how often do you drink alcohol?
Have you ever taken any drugs?
Yes
No
Are your vaccines current?
Yes
No
If employed, name of employer
If employed, current income?
Are you ok with flying on an airplane?
Yes
No
Have you traveled out of the US in the last 6 months?
If yes, where did you travel?
Do you have any upcoming travel plans in the next 12 to 18 months? If so, explain.
Are you ok with injections?
Yes
No
Have you ever placed a child for adoption?
Yes
No
How many sexual partners have you had in the last 5 years?
How many sexual partners have you had in the past 12 months?
Is your partner employed?
No
Full time
Part time
What kind of work does your partner do?
Name of Employer of Partner
Current Income of Partner
Is your partner currently active in the military or reserves?
Have you or your partner ever had psychological counseling?
Yes
No
Have you or your partner ever been hospitalized for psychiatric illness?
Yes
No
Have either you or your spouse/partner ever been in a substance abuse program (including AA, NA, etc.)?
Yes
No
Have either you or your spouse/partner ever filed for divorce, dissolution, or legal separation?
Yes
No
Why would you like to become a Surrogate?
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Are you comfortable working with a same sex couple?
Yes
No
No preference
Are you comfortable working with a single male?
Yes
No
No preference
Are you comfortable working with a single female?
Yes
No
No preference
Are you comfortable working with an older couple?
Yes
No
No preference
Are you comfortable working with a couple using a sperm donor?
Yes
No
No preference
Are you comfortable working with a couple using an egg donor?
Yes
No
No preference
Are You Comfortable Working With A Couple living outside the US
Yes
No
No preference
Are you comfortable working with a non-English speaker with a translator?
Yes
No
No preference
Are you comfortable working with a couple with children?
Yes
No
No preference
Are you comfortable working with a heterosexual couple?
Yes
No
No preference
Would you be willing to pump, freeze, and ship your breast milk if your IP requested it for their child?
Yes
No
Please give your feelings about the possibility of carrying twins or triplets
Please list any circumstances in which you would NOT consider working with an Intended Parent(IP) :
At the birth of the baby, are you comfortable with your IP being in the delivery room?
Yes
No
Undecided
Do you have any plans to move out of the state in the next 2 years?
*
Yes
No
Please describe the relationship you would like to have with your Intended Parents.
*
What would you like to share with the IP about your desire to help them build a family?
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What assurance can you give IP(s) that you will not change your mind about relinquishing the child?
If the child wants to speak to you or meet you in the future, wouId you be open to that?
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Yes
No
Undecided
What kind of support will you receive from your family (parents, in-laws, siblings)?
*
What kind of support will you receive from your friends and co-workers?
*
What kind of support will you receive from your spouse/partner?
*
What is your favorite color?
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Where would you most like to travel, and why?
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What physical activities do you enjoy?
*
Please describe your character and personality.
*
What are your favorite foods?
*
What are your favorite books?
*
Please describe your childhood.
*
What is your favorite type of music?
*
Name of Reference 1
Phone Number of Reference 1
Name of Reference 2
Phone Number of Reference 2
In case of emergency, please contact: (Please do not list your spouse/partner)
Emergency Contact Number
