Gestational Surrogate Application

 Please answer all questions in a truthful and factual manner to the best of your ability.  All identifying information will be kept confidential and will not be released to potential recipients without your permission.

U.S. citizenship status

What is your ethnic background?

Are you a registered member of an American Indian (Native American) tribe?

What is your marital status?

How did you hear about Family Choice Surrogacy?

Are you working with another agency?

Have you ever been rejected by another surrogacy agency?

Have you given birth before?

Are you actively raising your child(ren) or have actively raised?

Do you have implant birth control or have had implant birth control in last 6 months?

Are you currently pregnant?

Have you had more than 2 C-sections?

Have you had more than 2 miscarriages?

Are you currently a member of the US military?

Have you ever tested positive for HIV?

Have you previously had chicken pox or received the varicella vaccine?

Have you been vaccinated for MMR (measles, mumps, rubella)?

Have you ever been immunized for Hepatitis B?

Do you currently smoke cigarettes or use tobacco products?

Were you ever a tobacco smoker? If yes, when and how long?

Do you have any history of smoking cigarettes or using tobacco products during any of your prior pregnancies?

Do you currently use recreational drugs or drink alcohol excessively?

Do you have a history of recreational drug use or alcohol abuse? If yes, please provide detail below.

Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months? If yes, please provide detail below.

Have you ever had a psychiatric hospitalization? If yes, please provide detail and for how long below.

Have you ever been diagnosed with any severe psychiatric disorder? If yes, please provide detail below.

Has any member of your current household ever been diagnosed with mental illness? If yes, please provide detail below.

Have you or anyone in your household been convicted of a felony?

Are you or any member of your household a registered sex offender?

Are you receiving any of the following forms of government financial assistance?

Are you financially stable?

Your family. Your choice.

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