Skip to main content
Earthly Angels

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       


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-


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.


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


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?

Earthly Angels
Mississippi, California & Arkansas

Phone: 662.312.4487