GC - Initial Intake | Journey Surrogacy

If you have already applied with us, please log into your user portal here: journeysurrogacy.o-jms.com/user

First Name:

Middle Name:

Last Name:

Date of Birth:

Sun Mon Tue Wed Thu Fri Sat

Email:

Phone Number:

Street Address:

City:

State:

Zip Code:

Height:

'

"

Weight:

lbs

Race:

Religion:

Have you ever been a surrogate before?

If so, please explain your previous experiences:

Have you or anyone in your immediate family had any challenges getting pregnant, repeated miscarriages or have had children with health issues?

If so, please explain:

How many children have you given birth to?

Please list first first name, DOB, weight, and weeks of gestation for any prior births:

Have you ever given a child up for adoption?

If yes, please describe the circumstances:

Did any of your children require medical attention after birth?

If so, please explain:

Are your children healthy?

Please list any health concerns:

Have you or one of your children seen a doctor 3 or more times in one year for health issues?

If yes, please explain:

Do all of your biological children live with you full time?

If no, please explain their living arrangement:

Do you have support from your partner, family and friends to pursue surrogacy?

Please describe how they do or why they don’t support your decision to pursue being a surrogate:

List all the people that live in your household. Please include first names, relationship to you, and

current age.

Please list any family that lives near you:

What support will you have in your community (friends and family) for your surrogacy?

How much childcare do you currently use and how much does it cost you, on average, per week?