Intended Parent Application

Intended Parent Application
Primary IP Information

Section 1
Primary IP Name

First NameLast Name
Primary IP Other names used/Maiden name
Primary IP Email
example@example.com
Primary IP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary IP Date of Birth

MonthDayYear
Primary IP Age
Is the Primary IP a US Citizen or Green Card holder?
If the Primary IP is a Green Card holder, when does your Green Card expire?
Primary IP Marital Status
Ex: Married but separated, Married, Single, etc.
Primary IP Occupation & Employer
Ex: Office worker at Amazon
Primary IP Primary Language
Ex: English, Spanish, Ect
What Other Language/s is the Primary IP fluent in?
Ex: English, Spanish, Ect
What is the Primary IP’s preferred contact method?
Primary IP City and State of residence
Ex: Nashville, Tennessee
Primary IP Time Zone
Ex: ET, CT, PT, ECT.
Does the Primary IP have a valid drivers license or state ID
Does the Primary IP have reliable transportation?
Secondary IP Information

Section 2
Secondary IP Name

First NameLast Name
Secondary IP Other names used/Maiden name
Secondary IP Email
example@example.com
Secondary IP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary IP Date of Birth

MonthDayYear
Secondary IP Age
Is the Secondary IP a US Citizen or Green Card holder?
If the Secondary IP is a Green Card holder, when does your Green Card expire?
Secondary IP Marital Status
Ex: Married but separated, Married, Single, etc.
Secondary IP Occupation & Employer
Ex: Office worker at Amazon
Secondary IP Primary Language
Ex: English, Spanish, Ect
What Other Language/s is the Secondary IP fluent in?
Ex: English, Spanish, Ect
What is the Secondary IP’s preferred contact method?
Secondary IP City and State of residence
Ex: Nashville, Tennessee
Secondary IP Time Zone
Ex: ET, CT, PT, ECT.
Does the Secondary IP have a valid drivers license or state ID
Does the Secondary IP have reliable transportation?
Family And Fertility Information

Section 3
Does the Primary IP or the Secondary IP have any children? If yes, please specify below how many children you have and how they were conceived.
Ex 1: The Primary IP has 2 children, both conceived via IVF and the secondary IP has one child via adoption. Ex 2: The Primary IP and Secondary IP have 2 children together, one that was conceived naturally and one that was conceived via IVF.
Has the Primary IP or the Secondary IP worked with a surrogate before either with or without an agency?
Ex 1: Yes, The Primary IP has 1 child via surrogacy. Ex 2: No, We have never worked with a surrogate privately or with an agency before.
What led you to pursue surrogacy?
Ex: Same-Sex couple, Medical Condition, Single parent, Other.
Do you already have embryos created?
If yes to the above question…
How many embryos do you currently have?
Embryo quality (If known)?
Have your embryos been PGT-A tested?
What Clinic are your embryos located at?
If no to the above question, Please explain your plans to get embryos (Please include plans to use an egg donor, sperm donor, etc)
Ex 1: We are in the process of having embryos created. Ex 2: We are planning to start the process to have embryos created in the near future.
Financial Information & Household History

Section 4
Are you financially prepared for the costs associated with surrogacy? (Typically averages around $80k-$150k) Please include your plans to fund your journey.
Ex 1: Yes, We are prepared to cover the costs associated with surrogacy. We are planning to use financing arrangements and savings to fund our journey. Ex 2: No, We are still in the process of figuring out how we are going to fund our journey.
Please check all that apply:
How often does the Primary IP drink alcohol?
How often does the Secondary IP drink alcohol?
Please check all that apply:
Please check all that apply:
Mental Health Questions: Please select all that apply.
Does the Primary OR Secondary IP currently take any medications to treat depression or anxiety or have you in the past 6 months?
Please use this box to explain any of the above questions in this section.
Has the Primary IP or the Secondary IP ever had a bad result from an evaluation/pap? Example: Positive for an STD, HIV, Hep B or C, STI, Tuberculosis, etc? If yes, please explain below.
Was the Primary IP’s most recent evaluation or pap normal?
Was the Secondary IP’s most recent evaluation or pap normal?
When was the Primary IP’s last evaluation/pap?
If unknown type “unknown”
When was the Secondary IP’s last evaluation/pap?
If unknown type “unknown”
Feel free to add anything below that you would like us to know regarding the questions above OR any info you would like to share with us.
Are you currently working with another Surrogacy Agency or Independent match?
If yes to the above question, Please explain.
Ex 1:Yes, We are currently in the process of another surrogacy journey with a different agency. Ex 2: Yes, We are currently doing an independent journey.
How did you hear about Woven Branches Surrogacy?
Please explain the above if you selected “Other” OR share the name of the person who referred you to us. (So we know who to thank).
Consent & Signature

By Submitting this application, I confirm that the above information is true and complete to the best of my knowledge. I understand that this is an initial intake form and that further steps will follow to determine eligibility and match readiness.
Today’s date

MonthDayYear
Signature
Should be Empty:

Intended Parent Application

Primary IP Information

Secondary IP Information

Family And Fertility Information

If yes to the above question…

Financial Information & Household History

Consent & Signature