See if you meet the basic qualifications to become a surrogate!

WOMEN HELPING WOMEN BECOME SURROGATES

To Begin, please take two minutes to complete the following questionnaire to see if you meet the basic qualification requirments to become a surrogate.

Name*

Last Name

DATE OF BIRTH*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HAVE YOU GIVEN BIRTH TO AT LEAST ONE CHILD? *

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Have you ever been convicted of a misdemeanor or a felony?*

Note: if your record was expunged, you do not have to state "yes"

If yes, provide the date, the charge, some details about what occurred and the final disposition including fines, serving time, probation or any other requirements.*

Do you currently take any medications?*

If yes, indicate the name of the medication and what condition it is treating:*

Did you have any complications during any of your pregnancies or deliveries or complications after delivery related to your pregnancy?*

Complication include but are not limited to: hypertension, low amniotic fluid, ectopic pregnancy, miscarriage, gestational diabetes, anxiety requiring medication or any other health issue. Note: We will request prenatal ob/gyn and hospital delivery records for review.

If yes, you had complications during any of your pregnancies or deliveries or complications after delivery related to your pregnancy, describe below what the complications was.

Do you smoke cigarettes or vape?*

If you smoke or vape, indicate what product you smoke or vape and how often:*

Do you use recreational drugs?*

If you use recreational drugs, indicate which drugs you use:

Have you experienced post partum depression (PPD) requiring medication or counseling?*

(Note: sometimes PPD can be wrongly diagnosed or notated on you medical records as PPD and it is more situational and not PPD)

If yes, or not sure, provide details of any depression or anxiety that you experienced post partum along with any medications you were prescribed.*

Body Mass Index (BMI)*

Do you have reliable transportation?*

Do you live in government housing?*

If yes, you do live in government housing, indicate which type below:

U.S. CitizenU.S. Permanent ResidentOther

Are you working with any other surrogacy agency or independently with Intended Parents or are you listed on any matching sites as a surrogate?*

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