Have you been a TS, GS or ED before? MATCHED
If so, how many times?
First Name: Jolene Birth date: 12/8/80 Age: 33
City: Beebe State: Arkansas
Hair: brunette Eye color: hazel
Height: 5’4 Weight: 197 BMI: 33
Sexual orientation: heterosexual
Marital Status: Single
Surrogacy Information
Base Compensation: $ 20,000
Are you asking for extras? Yes If so, please list the amounts below (all long distance travel, legal and medical not covered by your insurance are automatically covered).
Transfer Fee (if GS): 500
Multiple fee: 2,000
Maternity clothing: 500 singleton and 700 twins
Lost wages: 350 week/ $70 per day/ $12 hour
Life insurance: 200,000 policy at a max of $250 per year
Childcare for appointments: None
Childcare/Housekeeping for bed rest: Childcare not needed. Housekeeping $50 weekly
Loss of reproductive organs fee: 3,000
C-section: 2,000
Invasive procedures: 250.00
Anything else: Medical insurance will be approximately $300 per month
When are you willing/able to start? Now
Are you willing to work with:
Single Intended Father: Yes
Single Intended Mother: Yes
Intended Fathers (couple): Yes
Intended Mothers (couple): Yes
Married Traditional couple: Yes
Unmarried Traditional Couple: Yes
Inter-racial: Yes
People with children: Yes
International (you do not have to travel there): Yes
International (limited English, but communicates well with online translator) Yes
Different race: Yes
Intended Parents using an Egg Donor: yes
Intended Parents using a Sperm Donor: Yes
Maximum age of Intended Parents: No max
Do you own a car? Yes
Do you have children (this is a requirement)? Yes
Ages of children: 2 boys- ages 12 and 14
Do any of your children have any health problems? No
If yes, what are they?
Have you ever placed a child for adoption? No
If yes, dates and explain.
Ethnic background (German, Indian, Irish, etc): Race: Caucasian
Religious background: Christian-non-denominational
Do you attend Church, etc.? Yes
Do you own or rent your home? Rent
Do you have any tattoos? Yes If so, how many? 14 (most are not visible)
Do you have any piercings? ears If so, how many? 2
Have you received any tattoos or piercings in the last six months? No
Do you use recreational drugs? No
Do you drink alcohol? Occasionally
If yes, how often: 2-3 times per year Are you willing to refrain during pregnancy? Yes
Do you smoke? No Does your spouse/partner smoke? N/A
And any person in the house who smokes must do so outside. Is this acceptable to you? Yes
Do you have cats? No
If so, are they kept inside or outside?
Have you or your spouse/partner ever been convicted of a felony in any state or country? No
If yes, please explain.
What is the closest major airport to you and distance? Little Rock, AR approximately 45 minutes away
Employment Information
Are you employed?: Yes
Length of time at employment: 4 years Position held: take-over manager
What is your work schedule? Monday-Friday 9AM-2:30PM and every other Saturday
Regarding your current employment, please describe the duties required of your job? Mainly phone work
Will your employer be flexible with your need to take time off for embryo transfers and medical appointments, court proceedings and for the birth of the child/children? Yes
Insurance
Name of health insurance company: None yet
If none, is it available through yours or spouse’s employer? No
Does it have maternity coverage? Does it cover a Surrogacy pregnancy?
Effective date: Deductible:
Amount of co-pays: What is the % of your coverage (80/20, 100%, etc)?
Is your insurance policy through your employer or your spouse’s employer? None
Do you understand that you are not allowed to use State Insurance (unless it’s through an employer) to cover any part of a surrogacy, including pregnancy and delivery? yes
Surrogacy Information
If you have been a surrogate before, please explain (dates, details and outcome). 2008 failed transfer
Did you use an agency or go independent? Earthly Angels
Please describe experience with agency. It was great J
Have you ever been rejected by a Reproductive Endocrinologist? No
If yes, please explain.
Do you have any testing already completed (STD blood work, psychological exam, etc)? No
If so, what and when?
Have you been vaccinated for Hepatitis A, B or C? No
Would you be willing to consider Intended Parents that wish to remain anonymous or semi-anonymous? Yes
How much communication do you expect or desire with the Intended Parents before a pregnancy is established? As much as the IPs are comfortable with
How much communication do you expect or desire with the Intended Parents after a pregnancy is established? As much as the IPs are comfortable with
How much communication do you expect or desire with the Intended Parents after the baby(ies) are born? As much as the IPs are comfortable with
Would you be willing to pump breast milk and/or breastfeed? Yes to both
If so, for how long? Up to a year
Are you willing to allow the Intended Parents to be significantly involved in the decision-making regarding the pregnancy? Yes
How do you feel about carrying multiples? Fine with it
What are your views on termination and selective reduction? If medically necessary or recommended by doctor to protect my health.
Are you willing to reduce if recommended by the treating physician? Yes
Do you understand the process of reduction or termination? Yes
Will you allow the Intended Parents to make all decisions regarding the termination of the pregnancy? Yes
Please list the reasons that you would not terminate: No
Would you terminate a child with Down syndrome? Up to IPs
Are you willing to do an amniocentesis if recommended or wanted by Intended Parents (only if blood work is abnormal)? Yes
Are you willing to do a CVS if recommended or wanted by Intended Parents (only if blood work is abnormal)? Yes
Are you willing to travel for IVF or IUI? Yes
Are you willing to deliver in another State? Yes, but AR has good laws
How many cycles are you wanting to attempt (Average is 3 as a GS and 6 as a TS)? 3
How can you reassure your Intended Parents you will not back out of your commitment to help them? I do not want any more children. I’m doing this to help someone else, not hurt them.
Would you like your Intended Parents to be in the delivery room when their child is born? Yes
If so, would you like one or both Intended Parents in the room with you? Both
What qualities are most important to you in Intended Parents (religion, personality, etc)? Someone caring and has the desire to have a child.
How do you feel about the possibility of the child wanting to meet you in the future? Ok with that
Some Intended Parents live in other states or countries, therefore their personal involvement with pre-natal care might be limited. Is this acceptable to you? Yes
If not, why?
How important is it to you that you meet the Intended Parents in person before moving forward as their surrogate? Not necessary but open to it
Do you understand that you shall not have custody or legal rights of any child/children born as a result of your pregnancy if you become a surrogate? Yes
It is a requirement by attorneys and clinics that you must submit to a psychological evaluation. Are you ok with this? Yes
Who will support you emotionally throughout and after the surrogacy? Friends, family and Sharron
Do you belong to any support groups (in person or on-line)? No
How do your extended family and/or friends feel about your decision to become a surrogate mother? Supportive of my decision
Is there anyone in your life that you know of, that is not supportive of your decision to become a surrogate? No
If yes, please explain.
Obstetrical/Gynecological Information
Do you have any preference as to an obstetrician? No
Are you sexually active? Yes
Have you ever had a sexually transmitted disease? No
If yes, explain.
Do you have a regular menstrual cycle? Yes
If yes, how many days between periods? (Day 1 being the first day of your period) 28 days
Are you currently breastfeeding? No
If so, when do you plan to stop?
Do you understand that you will not be able to begin the process until you are done breastfeeding?
When was the 1st day of your last menstrual period? 1/9/14
Did your mom ever take DES (diethylstilbestrol) or any other prescription medications while she was pregnant? No
If yes, explain.
What are your children’s names, gender, ages, birthdays and birth weight??
Isaiah-boy 3/27/2000- 7.15 lbs-
Preston-boy-11/11/2001-7.6lbs
Were all of them carried at least 37 weeks? Yes If not, please give details:
Have you been pregnant with multiples? No
Have you had any miscarriages? yes If yes, how many and how far a long were you: 1 miscarriage in 1997, but had 2 healthy pregnancies after that.
Were any of the children delivered via c-section? No If so, please list reason:
Have you ever experienced any pregnancy or delivery complications such as, pre-term labor, gestational diabetes, Placenta Previa, bedrest, etc.? none
Date of last pap smear? 2013
Result: Normal
Have you ever had an abnormal pap smear? No
If so, what was the reason and medication prescribed or procedure for it?
What form of birth control are you currently using? Birth control pills
How long? 1 year
Medical History Information
Blood type: A+
Are you of Jewish Ancestry? No
Are you of Black Ancestry? No
If so, do you have any family history of Sickle Cell Anemia?
Are you of Mediterranean (Greek or Italian) Ancestry? No
If so, do you have any family history of Thallasemia?
Have you or a member of your family had any of the following?
If yes, list dates, treatments and family member with disorder below.
AIDS/HIV: No
Diabetes: No
Cancer: Yes-Grandmother-Liver cancer
Hypo or Hyper Thyroid: Yes
High blood pressure: No
Heart Disease: No
Migraines: No
Psychological disorder: No
Are there any other genetic diseases in your family that aren't listed? No
Are you allergic to any medications? No If so, please list medication and reaction:
Are you currently under a physicians care? No
If yes, explain
Are you currently taking medications? No If so, please list medication and reason:
Have you ever had surgery? Yes
If yes, give date, procedure and reason: Gallbladder removed-2009 and tubes tied-2002
Education
Did you complete high school? Yes
If so, what year did you graduate? 1999
Did you attend a college or university? No
If so, when and where.
Years attended:
Course of study:
Diploma/certificate earned?
Other training/certificates: Licensed manicurist
Do you have any further educational plans/goals? Not at this time
Please explain.
Miscellaneous Information
Have you or your spouse/partner ever been in a psychiatric hospital or under psychiatric care?
If yes, please explain. No
Describe your personality? I’m a people person
Please describe your diet in detail: (vegetarian, vegan, etc.) Try to stay away from fried foods
Do you exercise? Yes
If yes, what and how often. Zoomba and Yoga once a week
Have you ever lived in another country? No
If yes, when and where.
What languages other than English do you speak? No Write?
