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208.284.7748 Apply

Intended Parents Surrogates How We Work Costs Stories FAQ Journal Contact 208.284.7748

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Apply to become a gestational surrogate

Your application opens a private, no-pressure conversation with our boutique team — not a commitment.

What to expect

✓ Personal response within 24 hours
✓ Private, unhurried consultation — free, no commitment
✓ We’ll ask about health, history, and home life — be honest
✓ Want the requirements first? See Surrogate Qualifications

← Back to information for surrogates

Prefer to talk first? Call 208.284.7748 or email rockymtnsurrogacy@live.com

Fields marked with an * are required
First name*
Last name
Intended Surrogate's date of birth*
MM slash DD slash YYYY
Spouse's full name
Spouse's date of birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long have you lived at this address?
Phone
Email
Occupation
Work phone
Name of employer
Address of employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
First name only*
Surrogate's occupation*
Surrogate's monthly income*
Surrogate's height*
Surrogate's current weight*
Surrogate's race*
Are you a U.S. citizen?*
Current city you live in
Current state you live in
Intended Surrogate's date of birth*
MM slash DD slash YYYY
What is your marital status?
- Married
- Single
- Domestic Partnership
- Divorced
- Widowed
- Separated
First name of your partner*
Partner's date of birth
MM slash DD slash YYYY
Would you like to have children in the future?
- Yes
- No
What is your religious background?
Do you practice?
- Yes
- No
Do you have any couples or individuals that you would NOT be willing to work with?
Have you applied to other Surrogacy agencies?
- Yes
- No
How did you hear about us?
MANY CLINICS WILL REQUIRE YOU TO SEND YOUR LABOR AND DELIVERY RECORDS FROM THE HOSPITAL AND YOUR PRENATAL RECORDS FROM YOUR OB/GYN FOR ALL BIRTHS. PLEASE START REQUESTING THESE AT THIS TIME
Do you currently have health insurance?
- Yes
- No
If yes, what is your deductible?
What is your max out-of-pocket?
Is your insurance through an employer?
- Yes
- No
Who is your health insurance provider?
If you have any allergies, please list them below
Do you take any medications at this time? And why?
Please list the number of pregnancies you have had
How many of your pregnancies were live births?
How many of your pregnancies were miscarriages?
How many of your pregnancies were abortions?
Pregnancy #1: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
Pregnancy #2: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
Pregnancy #3: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
Pregnancy #4: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
Pregnancy #5: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
Pregnancy #6: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds
If you experienced a miscarriage, please state the date and how far along you were
If you experienced an abortion, please state the date and how far along you were
Are your menstrual periods regular?
- Yes
- No
Is there anything unusual about your cycle? Please explain:
Are you currently on birth control?
- Yes
- No
If you are on birth control, what type?
Do you smoke?
- Yes
- No
Does anyone in your household smoke?
- Yes
- No
Have you ever used illegal drugs? If so, please list them below*
Do you have a criminal record?
- Yes
- No
Do you have a record of eating disorders?
- Yes
- No
Would you be willing to undergo an amniocentesis?
- Yes
- No
Would you be willing to terminate if the intended parents choose to?
- Yes
- No
What reasons would you not reduce or terminate?
Would you be willing to terminate if the pregnancy would result in a child with Down Syndrome?
- Yes
- No
What surgeries have you had and when?
Have you had any tattoos in the last 6 months?
- Yes
- No
Have you been seen by a professional for mental illness?
- Yes
- No
Have you experienced any postpartum depression?
- Yes
- No
Have you been prescribed any medication for mental illness?*
What is your blood type?
Rh Factor?
- Yes
- No
Have you delivered children with birth defects?
- Yes
- No
Are you with a sexual partner now?
- Yes
- No
How many sexual partners have you had in the past 3 years?
Have you had a sexually transmitted disease within the last 3 years?
- Yes
- No
Do you currently have more than one sexual partner?
- Yes
- No
What is the highest level of education you have completed?
What degrees or other trade experience do you have?
Briefly explain your understanding of what being a Gestational Carrier will entail?
Please describe yourself
What qualities would you consider most important that the intended parents have?
Why have you decided to become a Surrogate/Gestational carrier?
Would you allow the intended parents in the delivery room?
- Yes
- No
Would you allow the intended parents to attend doctor appointments?
- Yes
- No
Have you ever been a Surrogate/Gestational Carrier before? If yes, please explain your experience.
Have you ever placed a child up for adoption?
- Yes
- No
Are you adopted?
- Yes
- No
How do you feel about carrying Multiples? Twins or Triplets?
How much contact do you want following birth?
Do you feel confident that you will be able to give the intended parent(s) their child or children?
What type of support system do you expect to have through this experience?
All information provided in this application is true, accurate, and complete and to the Best of my knowledge.*
- I agree
Signature
Date
MM slash DD slash YYYY
I believe my wife/partner's response to this application is true, accurate and complete to The best of her knowledge. I am in support of her desire to become a gestational carrier.*
- I agree
Significant Other/Husband
Date
MM slash DD slash YYYY
A. Rocky Mountain Surrogacy, LLC did not induce, coerce me in my decision to become a gestational carrier*
- I agree
B. Rocky Mountain Surrogacy, LLC is not a party to my agreement with the Intended Parents*
- I agree
C. Rocky Mountain Surrogacy, LLC will be providing this application to potential parents both through hard copy and electronic formats. I acknowledge and agree that I will not be notified of such mailings and herby consent to the distribution of my application and photos to potential parents via mail and through electronic media such as email.*
- I agree
D. Therefore, I hereby agree to release and discharge Rocky Mountain Surrogacy, LLC and any of its representatives, agents, employees, and servants from all liability and all manners of action, suits, causes of actions, proceedings, debts, contracts, judgments, damages, claims, and demands whatsoever in law or equity in connection with my decision to become a gestational carrier or any adverse consequences which may arise in my connection with or as a result of my participation with this process. I hereby further agree to indemnify Rocky Mountain Surrogacy, LLC against any and all costs incurred in defending any such actions arising of this process. In the event that testing or screening has been completed and I choose not to move forward with the process I understand that any fees incurred on my behalf is my responsibility.*
- I agree
Applicant
Date
MM slash DD slash YYYY
If you have any questions about any information requested in this Application feel free to call us at (208) 284-7748 or ask below.

Rocky Mountain Surrogacy

A boutique surrogacy agency matching intended parents with gestational carriers since 2007. Personal, unhurried, and on call when you need us.

208.284.7748 rockymtnsurrogacy@live.com

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