Are you a U.S. citizen or permanent resident?

Yes

What is your relationship status?

How did you originally hear about SheCarries Partners?

Birth Control Method

Do you currently vape, use nicotine, weed or drugs?

Yes

Have you ever been diagnosed with a mental health disorder?

Yes

Are you on any medication?

Yes

Religious affiliation

Are you a Repeat Surrogate?

Yes

How many transfers did it take to have a successful pregnancy?

Number of Previous C-section(s)

Number of Previous Vaginal Births

Child 1 details: first name, DOB, birth weight, length, weeks delivered, vaginal or C-section

Child 2 details: first name, DOB, birth weight, length, weeks delivered, vaginal or C-section

Child 3 details: first name, DOB, birth weight, length, weeks delivered, vaginal or C-section

Child 4 details: first name, DOB, birth weight, length, weeks delivered, vaginal or C-section

Child 5 details: first name, DOB, birth weight, length, weeks delivered, vaginal or C-section

How long have you considered becoming a gestational carrier?

Any miscarriages/terminations

Any pregnancy complications

Any gestational diabetes

Yes

Any pre-eclampsia?

Yes

Unsure

Are you currently breastfeeding?

Yes

Unsure

Reasons for becoming a gestational carrier

Are you comfortable with international intended parents?

Yes

Unsure

Are you comfortable with independent journeys while a consultant guides you?

Yes

Unsure

Are you comfortable pumping breastmilk after delivery?

Yes

Unsure

Are you comfortable with same sex IP?:

Are you comfortable with a single IP either single dad or single mom?:

Yes

Not sure

For additional compensation, would you be willing to be a surrogate mother for a HIV+ IP if the HIV was not passed down to you?

Yes

Unsure

Are you willing to carry twins?

Yes

Twins only

If you are not willing to carry twins, please note twin pregnancies are considered higher risk pregnancies than carrying one baby. There are greater chances of bed rest and premature labor. Please confirm that you are willing to carry twins:

Yes

Twins only

If you prefer not to carry twins, there is less than a 5% chance the single embryo can split naturally. If it did, would you be willing to carry both babies?

Yes

Twins only

Are you willing to terminate a pregnancy if medically advised?

Yes

Unsure

If the fetus is diagnosed with Down syndrome(trisomy 21), would you be willing to terminate?

Yes

Unsure

If the fetus is diagnosed with a fatal or debilitating disease, would you be willing to terminate?

Yes

Unsure

Describe what kind of relationship you would like to experience with your intended parent:

Primary source of income

Have you ever been arrested?

Yes

Unsure

If yes, what crime were you charged with and when?

Are you willing to complete a background check?

Yes

Unsure

Educational background

Partner/Spouse First Name

Partner/Spouse Last Name

Partner phone number

Partner email address

What does your partner do for a living?

Does your partner have any prior arrest?

Yes

Unsure

Is your partner willing to complete blood testing for STDs and drugs?

Yes

Unsure

How long have you and your partner been together?

Who currently lives in your home?

Nicotine use in the household

Yes

Unsure

Please list the first names of family, friends, coworkers and children who will support you during your surrogacy process:

Current medications and dosages

Have you had any hospitalizations or surgeries?

Yes

Unsure

Hospitalization or surgery details and year

Are you currently in therapy or counseling?

Yes

Unsure

Most recent Pap smear year and result

Covid vaccination status

Yes

Unsure

Are you willing to receive other vaccines if requested by the IVF doctor?

Yes

Unsure

Do you cook at home or eat out more often?

Yes

Unsure

Is your menstrual cycle normal?

Yes

Unsure

Weekly workout frequency and exercise routine

What do you do for fun?

Are you willing to travel to Los Angeles for medical screening and embryo transfer?

Yes

Unsure

Health insurance provided by

Do you have an active driver's license?

Yes

Unsure

Do you have reliable transportation?

Yes

Unsure

What makes you a great gestational carrier?

Tell us about yourself and your family in one paragraph

Please text or email a few nice family photos of yourself. Ideally, these would be professional or well-shot photos where you are looking at the camera and smiling. Think holidays, birthdays, or vacations from the last two years. Please only send photos where you are either by yourself or with your child/children. The Intended Parents will see these.

I confirm that the information I provided is accurate to the best of my knowledge. I consent to SheCarries Partners reviewing this questionnaire for preliminary screening and, only with separate written consent, introducing my profile to a surrogacy agency. I understand that final eligibility, acceptance, matching, placement, and compensation are determined by the receiving agency and its medical, legal, background, and program requirements.