Gestational Carrier Application Process in Houston and Throughout Texas

If you would like to be a gestational carrier in our program, we would love to hear from you! Please call or email to schedule a completely free consultation with Katrina Cassidy to see if you meet the basic requirements and whether our program would be a good fit for you. You can also complete the application and email or scan it to us and we will contact you within one business day. We always have Intended Parent(s) ready to be matched now and are always looking for wonderful gestational carriers! Our compensation is very competitive and you will always be treated with courtesy and respect. You will not be asked to travel outside of Texas as most of the clinics we work with are in Houston and sometimes in Dallas. We are happy to provide you with referrals from other carriers who have been in our program as well. Call or email and schedule a consult with Katrina Cassidy P.C. today or complete the application!

Gestational Carrier Application

Submit your application and we will contact you within 48 hours. We look forward to hearing from you! If you need to save your answers and resume at a later time, scroll to the bottom of the form and click “Save and Continue Later”.

Gestational Carrier Information
Full Name*
Home Address*
Name of Employer
Contact Phone Number*
Email
Occupation
Date of Birth*
MM
DD
YYYY
Driver's License Number*
Gestational Carrier's Husband Information (if married)
Full Name
Occupation
Date of Birth
MM
DD
YYYY
Driver's Licence Number
Educational Background (select one)
Highest Level of Education Completed*
- High School
- 2 Year College
- B.A. or B.S.
- Graduate Degree
Physical/Pregnancy History
Please state your current height and weight*
Please state your BMI (body mass index) if known
Are you currently a smoker or have you ever smoked?
- Current
- Former
- Never
Please state whether you have drug allergies?
Please state whether you suffer from: (check all that apply)
- Asthma
- Diabetes
- High Blood Pressure
- Heart Defect
- Epilepsy
Are you currently receiving medical treatment for any illness or condition?*
- Yes
- No
If so, which that may affect pregnancy? (Ex. Thyroid, High Blood Pressure)
Are you currently taking medication for any condition?*
- Yes
- No
Have you ever diagnosed with a mental or psychological disorder or disability?*
Please identify any and all illnesses and conditions you believe you have or with which you have been diagnosed that may affect a pregnancy.*
Have you ever been cleared for an additional pregnancy by your OB GYN?*
- Yes
- No
How many pregnancies have you had?*
How many live births have you had?*
Please list how many weeks gestation each pregnancy was delivered*
How many C-sections have you had?*
Did you encounter any complications or problems with any of your pregnancies?*
- Yes
- No
If so, please identify any and all problems or complications.
Did you experience any of the following pregnancy complications? (check all that apply)
- Placental abruption
- Pre-eclampsia
- Hypertension
- Premature Birth
- Miscarriage
- HELLP
- Gestational Diabetes
If you had a premature birth, how many weeks?
Do you have medical records from your last pregnancy?*
- Yes
- No
If not, please provide the doctor/hospital name where those can be obtained.*
How do you prefer pre-natal care and delivery?*
- Hospital with OBGYN
- Home birth
- Midwife
- Birthing Center
Gestational Pregnancy
What kind of relationship would you prefer with the Intended Parents? (check all that apply)*
- Contact as necessary
- Frequent updates/emails
- Meet and socialize on a regular basis
How would you like to be contacted during the pregnancy? (check all that apply)*
- Text
- Email
- Call on phone
What frequency of updates to the Intended Parents would you be comfortable with? (Choose One)*
- Daily Updates
- Weekly Updates
- Bi-Weekly Updates
- Monthly Updates
What kind of relationship with the Intended Parents and the child do you envision after the child is born?*
- No contact
- Socialize occasionally
- As parents prefer
What is the maximum amount of embryos you would be willing to transfer? (typical number is two)*
Would you be willing to carry twins?*
- Yes
- No
Do you have a preference for which OBGYN and hospital you would use?*
- Yes
- No
If so please state the name of OBGYN and hospital.
Are you willing to allow Intended Parents to be present in the delivery room?*
- Yes
- No
Are you wiling to undergo a C-Section if recommended by the treating obstetrician?*
- Yes
- No
Are you willing to induce labor when and if recommended by the treating physician?*
- Yes
- No
Are you willing to terminate a pregnancy at the Intended Parent's request if there is a serious physiological or cognitive condition as diagnosed by 2 physicians?*
- Yes
- No
Are you willing to terminate or selectively reduce upon the recommendation of the treating physician?*
- Yes
- No
If there is a medical decision to be made that solely involves the safety and welfare of the child, are you willing to allow the Intended Parents to be the sole decision makers on all issues solely concerning any child born of this agreement?*
Do you understand that you will have no biological connection to the child (or children)?*
- Yes
- No
Do you understand that you (and your husband, if married) will have no rights to any child born under this gestational agreement?*
- Yes
- No
Do you understand that any child born under this agreement will be the legal child (or children) of the Intended Parents?*
- Yes
- No
When are you available to start the matching process?*
Do you have any major travel plans or events in the next year during which you would not be available for a transfer?*
- Yes
- No
Do you have any pre-existing scheduling with children and /or work that needs to be taken into consideration when scheduling doctor's appointments, testing, etc?*
Are you or your husband (or fiancé) currently a member of any branch of the military or reserves?*
- Yes
- No
Do you or your husband currently work in any employment where you are transferred out of state frequently?*
- Yes
- No
Psychological
Have you ever been a gestational carrier before?*
- Yes
- No
If so, may we contact your previous IP's as a reference?
- Yes
- No
Why would you like to be a gestational surrogate?*
Is your husband supportive and in agreement with your decision to be a gestational carrier?*
- Yes
- No
Is your immediate family supportive and in agreement with your decision to become a gestational carrier?*
- Yes
- No
Are you willing to attend a psychological screening visit with a counselor prior to the transfer?*
- Yes
- No
Compensation/Travel/Scheduling/Insurance
Are you willing to travel to a local IVF clinic for any testing and/or screening procedures, the embryo transfer, and any necessary follow-up medical care?*
- Yes
- No
Have you looked at the Gestational Carrier Compensation schedule on our website? If so, do you have any additional or different compensation requests not mentioned on the Schedule?
Do you have major medical health insurance that covers maternity?*
- Yes
- No
Name of Insurance Provider
- Cigna
- Aetna
- Blue Cross Blue Shield
Do you currently have a short term disability policy in place?*
- Yes
- No
Please provide any other information you believe the Law Office of Katrina Cassidy should be aware of in considering your abilities to serve as a gestational carrier.
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Please contact us with any questions. We offer a free initial 30 minute consultation.

Katrina Cassidy, P.C.

2002 Timberloch Place, Suite 200
The Woodlands, TX 77380

(281) 296-5797 (Telephone)
(281) 296-5899 (Facsimile)
(281) 844-8788 (Cellular)
kcassidylaw@comcast.net (Email)

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