Your Surrogacy Application Ready to help a family? Apply now. "*" indicates required fields Step 1 of 5 20% URLThis field is for validation purposes and should be left unchanged.Section BreakPersonal InformationName*Age*Date of Birth* MM slash DD slash YYYY Height*Weight*City and State*Ethnicity*Are you a permanent U.S. resident or citizen?* Yes No Have you ever given birth? (not qualified for surrogacy if your answer is No, no need to continue)* Yes No Number of Children*1234Vaginal Deliveries*Select Value01234C-Section Deliveries*Select Value01234Previous Surrogate?* Yes No Insurance* Yes No If answer “Yes” to above, insurance companyTermination of pregnancy if doctor or the intended parent requests* Yes No Have you used any form of tobacco or vape in the past 12 months?* Yes No Have you used any form of marijuana in the past 12 months?* Yes No Do you take any medications either over the counter or prescription?* Yes No Are you actively parenting at least one of your children?* Yes No Have you ever been convicted of a felony?* Yes No In the past 12 months have you received a tattoo or piercing?* Yes No Type of relationship* Single Divorced Married Spouse/Partner name (If applicable)Do you have a car for all the appointments?* Yes No Are you employed outside of the home?* Yes No If answer “Yes” to above, your current occupationIs your spouse/partner employed? Yes No N/A If answer “Yes” to above, your spouse occupationDid you graduate from high school?* Yes No Highest level of education*How many sexual partners have you had in the past 12 months* Psychological HistoryDo you now or have you ever taken any medications for psychiatric reasons?* Yes No Have you ever been treated at a psychiatric hospital?* Yes No Have you ever experienced psychological, physical or sexual abuse?* Yes No Are you currently taking any Anxiety or Anti-Depressant Medications?* Yes No Have you ever gone to therapy or counseling?* Yes No Have you ever attempted suicide?* Yes No Have you ever been treated for alcohol abuse?* Yes No Have you ever been treated for substance abuse?* Yes No Medical HistoryDo you or your partners have any STD's or STI's treated or untreated?* Yes No Do you have regular menstrual cycles?* Yes No Do you have any current or past medical issues?* Yes No Do you have any medical concerns that are untreated or you are worried about?* Yes No Do you have an untreated hypo or hyper thyroid?* Yes No Have you been diagnosed with high cholesterol?* Yes No Have you had an abnormal pap?* Yes No Do you have any allergies?* Yes No Are you at risk for AIDS?* Yes No Were the results of your last physical normal?* Yes No Do you do ANY drugs including medical marijuana?* Yes No Do you take any medications to help you sleep?* Yes No Have you ever had surgery?* Yes No Pregnancy HistoryHow many times have you been pregnant?*How many live births?*How many children do you have?*How old are they?Do they live with you?* Yes No Date of delivery #1*Full term* Yes No Pregnancy WeeksSurrogate Pregnancy?* Yes No Vaginal or C-Section*Singleton or Multiple*Complications with pregnancy*Delivery Hospital*Date of delivery #2Full term Yes No Pregnancy WeeksVaginal or C-SectionSingleton or MultipleComplications with pregnancyDelivery HospitalDate of delivery #3Full term Yes No Pregnancy WeeksVaginal or C-SectionSingleton or MultipleComplications with pregnancyDelivery HospitalHave you ever experienced infertility?* Yes No Have you ever delivered a child with a genetic abnormality or birth defect?* Yes No Have you ever placed a child up for adoption?* Yes No Preferred delivery hospitalYour current OB/GYN SurrogacyDo you have any concerns about surrogacy?*Are you willing to work with Intended Parent(s) that does not speak English (translation provided)?* Yes No Are you willing to work with heterosexual couples?* Yes No Are you willing to work with heterosexual singles?* Yes No Are you willing to work with same sex couples?* Yes No Are you willing to work with gay singles?* Yes No Are you willing to reduce caffeine during pregnancy?** Yes No Are you willing to carry for an HIV+ intended parent(s) through SPAR or HART program?* Yes No Not Sure Not sure? Click here to learn more.(after reviewing the info in a new window, return to the previous window to resume your application.)Are you willing to carry for HEP B+ Intended Parents* Yes No Not Sure Not sure? Click here to learn more.(after reviewing the info in a new window, return to the previous window to resume your application.)Are you willing to have the Intended Parent(s) present during the delivery? Yes No Is there anyone you would like to be there for the delivery (example: spouse/partner, mother, sister or friend):*Would you be comfortable with your Intended Parent(s) attending doctors’ appointments?*How would you like to have contact with your Intended Parent(s) during the pregnancy?*How often would you like contact with you Intended Parent(s) during the pregnancy?*How many embryos are you willing to transfer?*How many transfer attempts are you willing to attempt?*Are you willing to leave termination choices up to the Intended Parent(s) in the case of a serious birth defect?*Are you willing to leave termination choices up to the Intended Parent(s) in the case of a non-life threatening condition?*Are there any conditions under which you would not terminate?*If carrying triplets or more are you willing to reduce?* Yes No If recommended by a doctor are you willing to be placed on bedrest ?* Yes No When are you ready to begin?*Describe your support system*Do you have childcare available during pregnancy?*How did you hear about us?*If you were referred to our agency, list the name of the referralPlease submit photos of yourself, it is required that you submit at least three photos.*Max. file size: 1 GB. Please submit photos of yourself, it is required that you submit at least three photos.*Max. file size: 1 GB. Please submit photos of yourself, it is required that you submit at least three photos.*Max. file size: 1 GB. Please submit photos of yourself, it is required that you submit at least three photos. Drop files here or Select files Max. file size: 1 GB. Phone number (Internal Use Only)*Email (Internal Use Only)* By checking this box you confirm that the information given in this form is true, complete and accurate.* Yes Δ