Thank you for your interest in working with GS Moms on your surrogacy journey! Please fill out the screening form below and we will get back to you as quickly as we can.
What is your name?
What is your nickname?
What state do you live in?
What is the best way to contact you?
Do you live in the United States?
Do you live in New York, Michigan, or Nebraska
Do you speak and understand English?
Are you between the ages of 20 and 40 years old?
Have you used any tobacco products in the last year?
Do you have any history of illegal drug use or alcohol abuse?
Have you or your partner ever been convicted of a crime?
Have you used antidepressants in the last year?
Have you given birth to at least one child in the last 10 years?
Have you had two or more miscarriages?
Do you have at least partial custody of and live with at least one of your children?
Will you be dependent upon your surrogacy income as your primary means of support?
Are you currently accepting Welfare payments?
As part of the surrogacy process, are you willing to take injectable medications and oral birth control?
Would you be willing to terminate a pregnancy if medically advised to do so?
How old are you?
Date of birth
WhiteHispanicBlack or African AmericanNative Hawaiian or Other Pacific IslanderIndianAsianNative American or Alaska NativeOther
Your Cell Phone Number*
Your Home Phone Number
Your home address
Do you have health insurance?
If you have health insurance who is your health insurance provider?
How did you hear about us?
FriendWorkSchoolCraigs ListBarefoot StudentSearch EngineFacebookRadioAt Our BoothOther
If you were referred by a friend please let us know who to thank!
Do you have reliable transportation?
Do you have or have access to a computer?
When was your weight last obtained?
How often do you check your email?
ObsessivelyDailyWeeklyNot OftenHardly Ever
When would you like to start your Surrogacy journey?
ImmediatelyWithin a MonthWithin 3 MonthsJust looking for Information
Have you been a surrogate before?
When is the best time for our team members to contact you?
Does your household own a car?
If not, what is your means of transportation?
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