Advocates for Surrogacy

1

General Background Information

First Name*

Middle Name (optional)

Last Name*

Email*

Phone Number*

Date of Birth*

Street Address*

City*

State and Zip*

Do you have a valid driver's license and access to a vehicle?*

YesNo

How long have you lived at your current address?*

If you have lived at your current address for less than two years indicate your previous address. If not applicable just write "NA"*

List all adults living in your home. Indicate name, age, relationship to you. If none beside yourself, indicate "none"*

Are you receiving any public assistance?*

YesNo

If yes, indicate which benefits you receive. If no, write "NA".*

Do you plan to remain in your current state of residence for at least two years?*

YesNo

2

Employment and Lost Wages

Are you currently employed which includes owning your own business or freelancing?*

YesNo

3

Education

What is your highest level of education*

Do you hold any professional licenses, certifications, or vocational training? (e.g. cosmetology, nursing assistant, medical assistant, real estate) Are you currently studying for or working toward any license or certification? Please describe any that apply. If none, write "NA".*

4

Health Insurance

Do you have health insurance?*

YesNo

5

Emergency Contact

Name of Emergency Contact*

Email of Emergency Contact*

Telephone of Emergency Contact*

6

General Medical Background and Health History

Have you ever experienced any problems with your reproductive health including but not limited to failure to conceive, menstrual problems, ovarian cysts, endometriosis, Polycystic Ovarian Syndrome (PCOS), fibroids, Pelvic Inflammatory Disease?*

YesNo

Date of most recent pap smear and results.*

Have you ever had an abnormal pap smear?*

YesNo

Have you ever been a surrogate previously?*

YesNo

Are your immunizations up to date?*

YesNo

Have you ever been diagnosed with herpes, hepatitis B, hepatitis C, HIV/AIDS, syphilis, gonorrhea?*

YesNo

Have you ever been diagnosed with a mental illness, treated for a mental illness, been given medications for anxiety or depression or other mental health issues such as post partum depression?*

YesNo

Have you ever had a miscarriage, or have you ever terminated a pregnancy?*

YesNo

List any surgeries that you have had and the date. If you have not, indicate "None".*

List any medical illnesses or disease that you have. If none, indicate "None"*

Have you ever been advised by a doctor not to have more children or that future pregnancies could be risky for you?*

YesNo

Do you or anyone else in your home smoke or vape?*

YesNo

7

Reproductive Health and Pregnancy History

How many children have you given birth to? (If multiples during any delivery, just count as one child and you will be able to indicate both children in the birth weight section question below)*

8

Compensation and Reimbursements

Surrogate Compensation & Reimbursement Guide

At Advocates for Surrogacy, we provide a competitive compensation and benefits package. However, surrogates may require different compensation and benefits. The amounts indicated below are provided as a general guide only. You are not required to accept these amounts - you may set your compensation and reimbursements differently based on your own needs and circumstances. If you require any additional or different benefits or amounts, indicate in the spaces provided in this questionnaire.

Payments Prior to Pregnancy

1. $1,000 — Successful Completion of Medical and Psychological Assessment
2. $1,500 — Contract Signing after Full Clearance
3. $1,000 — Start of Medications (Lupron)
4. $1,000 — Embryo Transfer

Payments Upon Confirmation of Fetal Heartbeat

Base Compensation

First-Time Surrogates: $45,000–$50,000 ($4,500–$5,000/month × 10 months)
Experienced Surrogates: $60,000–$80,000 ($6,000–$8,000/month × 10 months)

Note: Surrogates who do not work typically request higher compensation due to no lost wages. Those living in high-cost urban areas also may request higher compensation.

Insured Surrogate Bonus: $6,000 ($500/month × 12 months)
Monthly Non-Accountable Fee: $3,600+ ($300/month × 12 months or longer)
Pregnancy Clothing Allowance: $1,000

Additional Compensation, Reimbursements and Benefits

Health Insurance (if needed): Provided at no expense to surrogate
Life Insurance: $750,000 policy
Lost Wages: For surrogate and spouse, for surrogacy-related appointments
Housekeeping During Doctor Ordered Bed Rest
Overnight Pet Care: $60/day at professional boarding facility
Child Care for Appointments (if not already enrolled)
Twin Pregnancy: Additional $10,000
C-Section: $7,000
Mock Cycle: $500
Dropped Cycle: $500 (in addition to start of medications)
Invasive Procedures (e.g., amnio, D&C): $1,500
Termination for Medical Reasons: $2,000
Selective Reduction: $2,000
Loss of Reproductive Organs: $7,500

Travel Reimbursements

Mileage: $0.71/mile (starts mile 1 before receiving monthly misc compensation, or starting 101st mile round-trip once receiving monthly misc payment)
Food: $50/day for surrogate, $50 for spouse/travel companion (8+ hr trips)
Pet Boarding: $60/day (must be licensed service with receipt)
Air Travel & Hotels: Arranged and paid by agency
Lost Wages: Paid in advance before travel
Parking/Uber/Tolls: Estimated and prepaid by agency

Escrow Protection

All compensation and benefits due you are secured in an independent third-party escrow account from the beginning through postpartum.

Insurance Information

Surrogates must have private insurance that covers maternity as a surrogate. Tricare and Medicaid cannot be used. If no qualified insurance is available, insurance will be purchased by the intended parents.

What base compensation are you requesting?*

After reviewing our compensation guide, indicate the base compensation dollar amount that you are requesting. This starts on the first of the month following confirmation of pregnancy by fetal heart beat and is paid in 10 installments during your pregnancy. Should your pregnancy be terminated or miscarriage occurs then your final payment is prorated during the month that the pregnancy terminated or you miscarried.

In addition to your base compensation above, you will receive a monthly miscellaneous fee of $300 per month starting on the 1st of the month following fetal heartbeat to cover surrogacy related travel under 100 miles round trip, parking, telephone, nonprescription medication, telephone, postage and faxing with no receipts required. Is $300 per month acceptable to you?*

YesNo

Indicate any compensation or reimbursement requests which differ or in addition to those outlined in our compensation guide.*

9

Child Care and Housekeeping

Do you currently have any children in child care?*

YesNo

If overnight travel is required, indicate how much will overnight care cost for your child/ren:*

If you have children who are not yet in school, how would you arrange care for them during medical appointments, some of which may require out-of-town travel?*

If bed rest is required by your doctor, will you require housekeeping?*

YesNoMaybe

10

Making the Right Match

What type of intended parent/s would you like to match with? (check all that apply)*

In the event that a fetal abnormality or medical condition is diagnosed during the pregnancy, and the intended parents request a termination, would you be willing to comply with their decision? Please share your thoughts in as much detail as possible.

Fetal conditions vary widely in their severity. Some surrogates feel differently about termination depending on the nature of the diagnosis. For example - a condition that is fatal or incompatible with life, Down syndrome, a chromosomal abnormality, a physical difference such as missing limbs or a facial abnormality. Are there specific diagnoses or conditions where you feel termination would not be something you could agree to, even at the request of the intended parents? Please be as honest as possible - there are no wrong answers, and your response helps us find the right match for you.*

11

Getting to Know You Better

Describe your childhood and life growing up. For example, where did you grow up, do you have siblings, childhood experiences.*

Do you have any particular goals for the future?*

What achievements in your life are you most proud of?*

Is there anything in your life you would do differently if you could? A "do over"?*

Describe your experience of being a mother. How do you spend time with your kids?*

Tell us about a significant experience in your life that has shaped who you are today. What happened, what was its impact, and how does it affect you now?*

Describe your current relationship status and what that looks like in your daily life. If you are married or with a significant other, share how you met and what your relationship is like. If you are single, share your thoughts on being a single mom.*

How does your family situation support your decision to become a surrogate?*

Why do you want to become a surrogate? Share any thoughts you have had over time about this or experiences that led you to consider surrogacy. If you have been a surrogate, describe what that experience was like for you. If you have not been a surrogate, just write "NA"*

Have you discussed becoming a surrogate with your spouse, significant other, family, friends? What were their reactions? Your thoughts about their reactions?*

If you have a spouse or significant other, are they fully supportive of your decision to become a surrogate? Please describe their level of support. If you do not have a spouse or significant other, write "NA".*

Describe your support system. Who are the people in your life you rely on, and how have they responded to your interest in becoming a surrogate?*

Surrogate Intake Questionnaire

General Background Information

Employment and Lost Wages

Education

Health Insurance

Emergency Contact

General Medical Background and Health History

Reproductive Health and Pregnancy History

Compensation and Reimbursements

Surrogate Compensation & Reimbursement Guide

Payments Prior to Pregnancy

Payments Upon Confirmation of Fetal Heartbeat

Additional Compensation, Reimbursements and Benefits

Travel Reimbursements

Escrow Protection

Insurance Information

Child Care and Housekeeping

Making the Right Match

Getting to Know You Better