Surrogate Intake Form

Surrogate Intake Form

Queer Surrogacy provides a comfortable and welcoming screening and application process. We aim to celebrate our LGBTQ+ applicants while getting to know them in an open and loving environment. We look forward to working with you.
Legal Name*

First NameLast Name
Preferred Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Pronouns*
Do you identify as LGBTQ+?*

YesNo
What is your sexual orientation and/or gender identity?*
Have you been a surrogate before?*

YesNo
Are you between the ages of 21 and 42 years old?*

YesNo
Do you have a body mass index (BMI) less than or equal to 30?*

YesNo
Are you currently raising at least one of your children in the home?*

YesNo
Have you completed at least one full-term, uncomplicated pregnancy and birth, with documented medical records?*

YesNo
Have you had 5 or fewer previous deliveries and 2 or fewer c-sections*

YesNo
Are you partnered or married?*

YesNo
Do you have the help and support of family. If married or partnered, have support from a partner or spouse.*

YesNo
Do you have any sexually-transmitted diseases?*

YesNo
Do you or anyone in your home use illegal drug use or abuse alcohol?*

YesNo
Are you or anyone in your home a cigarette smoker?*

YesNo
Do you have the ability to travel to a fertility clinic for the in-vitro fertilization (IVF) process as needed?*

YesNo
Are you free from felony convictions and can pass a background check and drug screening? If in a relationship, a partner or spouse must be willing to undergo a background check and drug screening.*

YesNo
Do you reside in the United States in a surrogate-friendly state (unfortunately, we cannot accept gestational carriers who reside in Nebraska, Louisiana, Michigan, or outside the US).*

YesNo
Do you or your children participate in government aid programs such as cash assistance, welfare, public housing, and section 8. All other forms of government assistance are to be considered on a case-by-case basis.*

YesNo
Are your covid-19 vaccinations up to date? Fertility clinics currently require covid-19 vaccinations to perform embryo transfers. If not, would you be willing to get the covid-19 vaccination before your embryo transfer?

YesNo
Our response times following submissions are between 24-72 hours. If you have not heard anything after 72 hours, please contact us at applications@queersurrogacy.com

By SUBMITTING THIS FORM, you agree to the following: 1) I give my permission to receive messages following my submission detailing my potential approval or denial. 2) I understand that submitting my initial application will not warrant immediate approval. 3) I understand that all answers will be assessed and scrutinized, with the goal being to achieve healthy pregnancies and relationships. 4) If needed, I am aware that I can reach out to Queer Surrogacy with any questions or concerns I may have about my application at info@queersurrogacy.com
Signature*

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