Surrogate Assessment

Your journey begins here. We’re honored to walk alongside you as you take this step. To help us move your journey forward quickly, please set aside about 15 minutes to complete this form.

Have ready: Valid ID, Proof of Address, Medical Records, and Pregnancy Records.
(Your OB Clearance Letter and Pap Smear report aren’t required now, but will be requested after submission to finalize your match.)

If you need assistance at any point, please visit our Surrogate Journey Guide.

Once submitted, check your email (and Spam/Junk folder) for your Welcome Email. For help, call (888) 408-2238.

Full name

Submission details

How did you hear about us? *

Select one * *

Contact & Basics *

First Name * Middle Initial (Optional) Last Name * Date of Birth * Gender * Citizenship * Marital Status * Do you have a valid Government ID? *

ID Type *

Upload Government ID (Front) *

No file selected

Upload Government ID (Back) *

No file selected

Which country do you currently reside in? *

Street Address * City * State * Zip Code *

Full Address *

Proof of Residency

Is the address you entered your current residence? *

Please specify *

Please enter your current residential address above before continuing.

Can you provide proof of residency? *

Can you receive mail at this address? *

Please specify *

Proof type *

Please specify *

Upload Proof *

No file selected

Accepted: PDF, JPG, PNG (max 10 MB).

Phone Number * Confirm Phone Number * Email * Confirm Email * Chat ID / Username * Preferred Contact Method * Best Time to Contact *

Earliest time * Latest time *

Preferred Language for Communication * Do you speak any other languages fluently? *

Do you require a language interpreter for meetings? *

* I consent to be contacted by phone, text, and/or email regarding this process and related updates. *

Resume (Optional)

No file selected

Accepted formats: PDF, DOC, DOCX.

References (Optional)

Add up to three references.

Emergency Contacts (Optional)

Used only if we cannot reach you directly.

Surrogacy Assessment *

What is your reasoning for becoming a Surrogate? *

Are you interested in Doula Services? *

Please select all doula services you are interested in:

* Birth Doula * Postpartum Doula * Antepartum Doula * Fertility Doula * Full-Spectrum Doula * Specialized Doula * Other

Budget per selected service

Select your budget preference for each service you chose above.

Please specify * Have you been a Gestational Carrier (Surrogate) before? * When was your last surrogacy journey completed? * Are you able to provide previous surrogacy medical records? * Would you like to upload now? *

No files selected

Max 100 MB per file.

What is your health condition? * Please specify * Do you have medical insurance? * Who is your provider? * Please specify * Can you provide your policy number? * Enter Policy Number *

Pregnancy History *

How many delivered pregnancies have you had? *

Total pregnancies (including miscarriages and abortion) * Total number of babies delivered * Total number of miscarriages * Total number of spontaneous abortions * Total number of therapeutic abortions *

Please explain the causes of miscarriages or abortions *

Total number of full-term delivery (>=37 weeks) * Total number of pre-term delivery (<37 weeks) * Total number of C-sections *

Medical History *

Have you been diagnosed with an STD before? *

Select all that apply:

* Chlamydia * Gonorrhea * Syphilis * Genital Herpes * HPV * HIV * Hepatitis B * Hepatitis C * Other

Please specify * Did you receive treatment? * Please specify treatment details *

Have you been diagnosed with any diseases? *

Select all that apply:

* Chronic Disease * Genetic Disease Carrier * General Genetic Disease * Other

Please specify * Did you receive treatment? * Please specify treatment details *

Have you had a blood transfusion? * Please specify * Did you have any surgeries in the past? * Please specify * Do you have any allergies? * Please specify * What is your blood type? * Please specify * Are you RH negative? * Do you require a RhoGAM shot during pregnancy? * Please specify * Have you had a Pap Smear within the last 12 months? * Do you remember the date of your last Pap Smear? * When was the last Pap Smear? * Was the last Pap Smear normal? * Please specify * Is your menstrual cycle regular? * Please specify * Are you currently taking any birth control pills or hormonal contraceptive measures? * What birth control method are you using? * Please specify * Have you experienced any abnormal vaginal bleeding? * Please specify * Are you Hepatitis B immune? * Please specify *

About You *

Would you like to disclose your Race/Ethnicity? *

(Optional) Select all that apply:

* African * African American * East Asian * South Asian * European * Latine * Middle Eastern/North African * Native/Indigenous * Other

Please specify *

Height * Weight (lbs) * Do you know your BMI? * Enter BMI * Do you have any physical disabilities? *

Select all that apply:

* Mobility impairment * Hearing impairment * Vision impairment * Other

Please specify *

What is your sexual orientation? * Please specify * Do you have any tattoos? *

Total number of tattoos * Please specify * Date of the last tattoo * Can you provide certificate of the tattoo shop if needed? * Please specify *

Do you have any body piercings? *

Total number of body piercings * Please specify * Date of the last piercing * Can you provide certificate of the piercing shop if needed? * Please specify *

Are you currently using any illegal drugs or controlled substances? * Please specify * Are you currently smoking or vaping? * Please specify * Are you currently drinking alcohol? * Please specify * What is your major? * Please specify * What is your highest level of education? * Please specify * Are you employed? *

Occupation * Employment status * Current Average Monthly Income *

Have you ever filed for bankruptcy? * Please specify * Have you been arrested or committed a crime? * Please specify * Have you been involved in any legal cases or any that are pending? * Please specify * Have you ever been in a psychiatric facility? * Please specify * Have you been in a substance abuse program? * Please specify * Do you drive and have your own reliable transportation? * Please specify * Is your Driver’s License expired? * Please specify * Does anyone in the household drink alcohol? * How often? * Does anyone in the household smoke? * How often? * Does anyone in the household currently use illicit drugs? * Please specify * Have you ever had any psychological counseling? * Please specify * Have you ever been hospitalized for psychiatric illness? * Please specify * Are you currently sexually active with anyone other than your partner listed on the application? * Please specify * Have you been physically abused? * Please specify * Have you ever had thoughts of or attempted suicide? * Please specify * Do you currently suffer from anxiety, bipolar disorder, or depression? * Please specify * Have you ever experienced any form of depression, including postpartum? * Please specify * Please tell us about yourself (For example, hobbies, education, occupation, life story etc.) *

Photos & Video *

Photos

Upload up to 5 supported files. Max 100 MB per file.

0 / 5 added

Intro Video (Optional)

No file selected

Max 100 MB.

Preferences *

Are you willing to carry twins? * Please specify * Are you willing to carry triplets? * Please specify * Total max number of embryos you are willing to transfer? * Are you willing to do amniocentesis if medically necessary? * Please specify * If fetal defects are found and the IP requests an abortion, will you agree to cooperate accordingly? * Please specify * Do you have any religious or personal beliefs that might affect your ability to follow a physician’s recommendations during pregnancy? * Please specify * Will you be open to keep in touch with the IP after the baby is delivered? * Please specify * Are you willing to save breast milk with extra compensation upon IP request? * Please specify * Are you willing to receive daily injectable medications? * Please specify * Are you willing to travel or drive to the IVF clinic when needed? (Compensated travel cost) * Please specify * Is your family aware and supportive of your decision to become a surrogate? * Please specify * Is your family supportive of your decision to become a surrogate? * Please specify * Do you have any specific preferences on families you will not match with? *

Select at least one:

* Race/Ethnicity * Height * Blood Type * Education Background * Lifestyle/Health * Other

Please specify *

What is your expected compensation? *

Spouse / Partner Information *

Do you currently have a spouse or committed intimate partner? * Do you have a Spouse or a Committed Intimate Partner? *

Partner Details *

First Name * Middle Initial (Optional) Last Name * Date of Birth * Gender * Citizenship * Marital Status * Do you have a valid Government ID? *

ID Type *

Upload Government ID (Front) *

No file selected

Upload Government ID (Back) *

No file selected

Which country do you currently reside in? *

Street Address * City * State * Zip Code *

Full Address *

Phone Number * Confirm Phone Number * Email * Confirm Email * Chat ID / Username * Preferred Contact Method * Best Time to Contact *

Earliest time * Latest time *

Preferred Language for Communication * Do you speak any other languages fluently? *

Do you require a language interpreter for meetings? *

* I consent to be contacted by phone, text, and/or email regarding this process and related updates. *

About Partner *

Upload Document(s) — Partner

No files selected

Max 100 MB per file.

Photos — Partner

Add one photo at a time (up to 5). Max 100 MB per file.

0 / 5 added

Intro Video (Optional) — Partner

No file selected

Max 100 MB.

Additional Information *

Would you like to add anything else? *

Please share details *

Upload Supporting Files (Optional)

No files selected

You may add multiple files of any type.

Drug Screen Authorization *

By signing below, I authorize the administration of a drug screen and the release of my drug screen results as necessary for program participation, screening, and care coordination.

Will you complete a drug screen if requested? *

* I agree to the above statement.

Signature for drug screen *

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Type your full legal name below. A cursive-style rendering will be saved.

Type your full legal name * Date *

Drug Screen Authorization Agreement

Drug Screening Consent Agreement

1. Purpose

The Applicant is required to undergo and consent to drug screening as a condition of participation with American Beginnings (“ABC”).

2. Consent to Drug Screen

By signing this Agreement, the Applicant voluntarily authorizes ABC, its medical partners, and designated laboratories to collect, process, and review biological samples (including but not limited to urine, blood, or hair follicle specimens) for the purpose of screening for controlled substances, prescription medications, and illicit drugs.

3. Scope of Testing

Testing may include, without limitation:

Amphetamines
Cocaine
Marijuana/THC
Opiates (e.g., heroin, codeine, morphine, oxycodone, hydrocodone)
Phencyclidine (PCP)
Benzodiazepines and barbiturates
Synthetic or designer drugs, as applicable

Additional panels may be required based on medical recommendations. The Applicant may be required to submit to follow‑up or random testing as determined by ABC or its medical partners.

4. Use of Results

Results will be used solely to determine eligibility for participation.
A positive test for unauthorized substances may result in immediate disqualification.
Refusal to participate or attempts to tamper with a test will be treated as a positive result.

5. Confidentiality

All drug screening information will be treated as confidential medical information and shared only with authorized parties involved in the screening process.

6. Acknowledgment

By signing below, the Applicant certifies that they have read, understand, and voluntarily agree to this Drug Screening Consent Agreement.

Psychiatric Evaluation Authorization *

By signing below, I authorize the administration of a psychiatric evaluation and the release of my evaluation results as necessary for program participation, screening, and care coordination.

Will you complete a psychiatric evaluation if requested? *

* I agree to the above statement.

Signature for psychiatric evaluation *

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Use your finger or mouse to sign above.

Type your full legal name below. A cursive-style rendering will be saved.

Type your full legal name * Date *

Psychiatric Evaluation Disclosure & Consent Agreement

Psychiatric / Psychological Evaluation Consent

1. Purpose

The Applicant consents to a comprehensive psychological and/or psychiatric evaluation as part of ABC’s screening process.

2. Scope of Evaluation

The evaluation may include clinical interviews, standardized assessments, and other tools administered by licensed mental health professionals.

3. Authorization to Share Results

The Applicant authorizes the evaluating professional(s) to share the evaluation results and professional recommendations with ABC, its medical and professional staff, and other parties directly involved in determining eligibility as a surrogate or donor.

4. Use of Information

Information will be used solely for determining suitability for participation and for coordinating any required care or follow‑up.

5. Confidentiality

Records will be treated as confidential health information and disclosed only as authorized by the Applicant or as required by law.

6. Acknowledgment

By signing below, the Applicant certifies that they have read, understand, and voluntarily agree to this Psychiatric / Psychological Evaluation Consent.

Medical Release Authorization *

By authorizing, you permit American Beginnings Consortium and its designated partners to obtain, use, and share necessary medical information (e.g., history, labs, genetic screening, infectious disease testing) to evaluate eligibility and coordinate services related to surrogacy. Sensitive information is handled in accordance with our privacy and data security policies, and disclosures are limited to what is necessary for screening, matching, and care coordination.

Are you willing to release your required medical information for our services? * * I agree to the above statement.

Signature for medical release *

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Type your signature (full legal name) *

A cursive-style rendering of your typed name will be saved.

Type your full legal name * Date *

Medical Release Authorization Agreement

Medical Records Release Authorization

1. Authorization

The Applicant authorizes the release of complete medical records, including but not limited to obstetric, gynecological, surgical, primary care, laboratory, and imaging records from all providers who have rendered care.

2. Purpose of Disclosure

Records will be used by ABC, its medical staff, and associated professionals to evaluate health history and determine eligibility as a surrogate or donor.

3. Sensitive Information

The Applicant understands these records may contain sensitive information and consents to disclosure for evaluation purposes only.

4. Duration and Revocation

This authorization remains valid until revoked in writing. Revocation will not affect disclosures made in reliance on this authorization before revocation is received.

5. Confidentiality

ABC will handle all received medical information in accordance with applicable privacy laws and professional standards.

6. Acknowledgment

By signing below, the Applicant certifies that they have read, understand, and voluntarily agree to this Medical Records Release Authorization.

Background Check Authorization *

American Beginnings Consortium may obtain consumer reports for screening related to your participation. If you qualify to proceed, a background check will be required. Sensitive identifiers may be provided directly to our secure screening partner; we do not store SSNs on this site.

Are you willing to undergo a background check? * When will you provide SSN? * Last 4 of SSN * * I agree to the above statement.

Signature for background authorization *

Sign Here

Use your finger or mouse to sign in the box above.

Type your signature (full legal name) *

A cursive-style rendering of your typed name will be saved.

Type your full legal name * Date *

Background Check Authorization Agreement

Background Check Authorization

1. Authorization

The Applicant authorizes ABC and its designated agents to conduct a background investigation, which may include criminal history, sex‑offender registry, driving records, employment history, education verification, and reference checks.

2. Sources of Information

The Applicant authorizes law‑enforcement agencies, former employers, educational institutions, and other relevant entities to release information for this purpose.

3. Use of Information

Results will be used solely to evaluate eligibility for participation in ABC’s programs.

4. Release of Liability

The Applicant releases ABC and entities providing information from liability arising from the lawful procurement, use, or disclosure of such information.

5. Copy Valid as Original

A copy of this authorization shall be considered as valid as the original.

6. Acknowledgment

By signing below, the Applicant certifies that they have read, understand, and voluntarily agree to this Background Check Authorization.

Terms & Acknowledgements *

* I affirm that all information provided in this assessment is accurate and complete to the best of my knowledge.

* I understand that the information provided will be used solely to determine eligibility and participation, and may be shared only with authorized personnel and as required by law.

* I acknowledge that I am completing this assessment voluntarily and of my own free will.

* I have read, understood, and agree to the terms outlined in each agreement presented in this assessment.

* By submitting this assessment, I consent to be contacted by American Beginnings Consortium Inc. regarding my application.