• Valley Surrogacy Consulting — Start Here: Pre-Vetting Intake

    I'm Julia. I'm not an agency, and this form is free — I never charge women. Some answers about surrogacy are hard to find until after you've already applied somewhere; this intake exists so you get honest answers first. Your answers pre-vet your profile so I can match you with the agency that's the best fit for you. This is educational only — not medical or legal advice, and final eligibility is always the agency and its clinic's decision, not mine. Your identifiable information is never shared without your written permission.

  • Applicant & Contact Information

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred contact*

  • Eligibility, Logistics, and Medical History

  • Are you a US citizen or legal resident?*
  • Do you have reliable transportation to get to medical appointments?*
  • Any of these in a past pregnancy?*
  • Postpartum depression that required medication or counseling?*
  • Any chronic health conditions?*
  • Are you currently taking any medications, including mental-health medications?*
  • Have you had any surgeries, including ablation?*
  • History of abnormal Pap results?*
  • Do you smoke, vape, or use nicotine in any form?*
  • Do you use recreational drugs?*
  • Alcohol use*
  • Does anyone in your household smoke indoors?*
  • Do you currently receive government assistance (such as food or housing assistance)?*
  • Any criminal history?*

  • Consent and Next Step

  • How would you like to connect next?*
  • Today's date (auto)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: