Let's start with the basics Welcome, and thank you for considering this. These first few questions confirm our basic requirements, so you'll know right away whether our program is a good fit before sharing anything more personal.
What name do you go by? *
Which state do you live in? * Select one… Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Which best describes your current U.S. status? * Select one… U.S. citizen Lawful permanent resident / Green Card holder Other current lawful immigration or residency status I do not currently have lawful U.S. status I'm not sure, and I'd like to talk it through Our program works with Surrogates whose status will stay in place through screening, pregnancy, and the legal steps after birth.
It's OK to text me about my questionnaire, including a friendly reminder if I leave before finishing. Message and data rates may apply.
Your answers are private. They're read by the Vias team and shared only with the professionals involved in your screening, such as a fertility clinic, psychologist, or attorney. Privacy policy
It's nice to meet you Tell us a little about where you are right now. There are no wrong answers here, whether you've been a Surrogate before or you're just beginning to learn about it.
When would you ideally like to begin? * Select one… As soon as possible Within the next 1–3 months Within 3–6 months More than 6 months from now I'm still exploring
Your pregnancies Every pregnancy story is different, and no one has a perfect history. We aren't looking for one. These details help the fertility clinic understand how your body has handled pregnancy before, so they can keep your health and safety in mind from the very beginning.
Here's what we have
This looks right.
Pregnancy and delivery complications Check anything you've experienced in any pregnancy. Many of these are more common than people realize, and each one is looked at thoughtfully and in context, never as an automatic no.
Tell us a little more.
Where things are today Just a couple of quick questions to help us understand timing.
How old is your baby?
What birth control are you using right now, if any? Select one… Birth control pill Hormonal IUD Copper IUD Implant Injection Patch Vaginal ring Tubal ligation Partner vasectomy Condoms or another barrier method Fertility-awareness method None Other
Reproductive and fertility history You're almost through this chapter. These last few questions help us understand whether there is anything a fertility clinic may want to review more closely later.
Share any details you remember.
What was it, why, and roughly when?
What treatment, roughly when, and how did it go?
How many, were they for your own family or a surrogacy, and what happened?
Your health Thank you for sticking with us
Your BMI Add your height and weight
Calculated from the height and weight you enter. BMI is just one part of the clinic's overall health review, and it's something we can talk through together.
Tell us when you were diagnosed, how you're doing now, and any treatment you've had.
Which medications, what they're for, and how long you've taken them. Include dose if you know it.
Roughly when, why, and how it went.
Roughly when and why?
Sexual and cervical health We understand these questions are personal, and we appreciate your openness. Many infections and cervical changes are common and treatable, and sharing them now simply means there are no surprises later.
Share any details you remember.
Emotional wellbeing How you feel matters just as much as how your body is doing. Pregnancy brings emotional changes too, and we'd like to understand what you've been through and what has helped. Having seen a therapist or taken medication doesn't rule anyone out. Share what you're comfortable with here, and anything else can wait until we talk.
Roughly when, whether you had treatment, and how you're doing now.
Have you taken medication for your mental or emotional health? * Select one… Yes, currently Yes, in the past No
Which medication, what for, and roughly when.
If you'd like, share any context. This is optional.
If you're having a hard time right now, you can call or text the 988 Lifeline, any time, day or night. It's free and confidential.
Nicotine, alcohol, and other substances Honest answers help most here. Timing matters more than history, so we ask about recent use separately from the past.
Cigarettes, vaping, or other nicotine * Select one… I use it now I stopped within the last 6 months I stopped 6–12 months ago I stopped more than a year ago I've never used it regularly
Marijuana or cannabis * Select one… I use it now I used it within the last 6 months I used it 6–12 months ago I last used it more than a year ago I've never used it
How often do you drink alcohol? * Select one… Never Less than once a month A few times a month 1–3 drinks a week 4 or more drinks a week I'd rather talk about this by phone
When did you last use them? * Select one… Within the last year 1–3 years ago More than 3 years ago
Which substance(s), and was it one time, occasional, or regular?
The people around you No one should go through this alone. Having people who can help with appointments, pregnancy, and recovery makes a real difference, and we'd love to know who's in your corner.
Relationship status * Select one… Married In a committed relationship, living together In a committed relationship, living apart Single Separated Divorced Widowed Other
How do they feel about it? * Select one… Very supportive Supportive, with some questions Unsure Not supportive We haven't talked it through yet
How many children are you raising? *
Who would that most likely be? Select one… Spouse or partner Parent Sibling Friend Other We'll ask for their contact details later, only if you move forward.
Your everyday life Life is already full. These questions help us picture how appointments would fit around your work and family, so we can plan with you, not around you.
Tell us a little about your situation, and we can talk through options together.
Work * Select one… Employed full-time Employed part-time Self-employed Stay-at-home parent or caregiver Student Not currently working Other
Could you usually make appointments during business hours? * Select one… Yes Most of the time With some advance planning No I'm not sure
How the process works In gestational surrogacy, the embryo is created through IVF using the Intended Parents' or a donor's egg. The Surrogate isn't genetically related to the baby she carries.
Before today, how familiar were you with how this works? * Select one… Very familiar Somewhat familiar Mostly new to me
How do you feel about taking clinic-prescribed medications, including injections? * Select one… Comfortable Open to it, but I'd like to know more Unsure I wouldn't be willing to take hormones or injections
Background Surrogacy includes formal background checks, so it helps for us to know about anything early. Please answer as openly as you can. If something needs more context, we'll talk it through with you.
Which one?
What happened? Select one… I completed a journey with them I was accepted but decided not to continue I withdrew I wasn't approved I'm in another process right now Other
If you know, what reason were you given? This is optional.
Please briefly share the charge, roughly when, the outcome, and any current probation or court requirements.
Please briefly share their relationship to you, the charge, roughly when, and the outcome.
A brief explanation.
A brief explanation.
Tell us a little about where things stand.
Insurance and benefits Insurance and benefits can affect how a surrogacy is set up. Knowing now means we can plan around it together and nothing catches you off guard later.
What health insurance do you have? * Select one… Through my employer Through my spouse, partner, or family An individual plan Medicaid or another government plan Other I don't have health insurance right now I'm not sure
Which program(s), if you know?
Just a few details You're nearly finished. We just need your legal name and address for our records.
Street address *
Best way to reach you Select one… Phone call Text message WhatsApp Email
Best time of day Select one… Morning Afternoon Evening Any time
How did you hear about Vias? Select one… Google or another search engine Facebook Instagram TikTok A friend or family member A current or former Surrogate A fertility clinic or doctor An attorney or other professional An event An ad Other
In your own words This is the part we look forward to reading most. None of it is required, but it helps us get to know you as a person, not just a list of answers.
What draws you to becoming a Surrogate?
Is there anything we didn't ask that you'd like us to know?
Is there anything you'd like to ask us?
Before you send this Thank you for your time and your honesty
My answers are complete and accurate to the best of my knowledge.
I understand Vias may ask for my medical records, and that doctors, a psychologist, attorneys, and insurance specialists may review relevant information as part of screening.
I understand that submitting this questionnaire doesn't guarantee acceptance, and isn't medical, psychological, or legal clearance.
What happens next
Someone on our team reads your answers personally and reaches out within two business days. We set up a time to talk, a relaxed conversation of about 45 minutes to an hour to get to know each other and answer your questions. If it feels like the right fit for both of us, we'll invite you to Phase 2, your full application. Back Save and finish later Continue Send my questionnaire
