Are you a mom with a big heart?
Becoming a surrogate with Reproductive Options allows you to help another family experience the joy of parenthood while also providing extra income to support your own. Take our short quiz to see if surrogacy could be the perfect fit for you and your family. Let’s start with the basics — just a few easy questions to get to know you better.
Contact and Background
Full name
*
First Name
Last Name
Email
*
example@example.com
Cell number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City and state
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Citizenship status
*
Please Select
U.S. Citizen
U.S. Permanent Resident
Other (please specify)
If other citizenship status, please specify
Would you pass a background check?
*
I have a clean record
I have a minor offense (like a DUI) from more than 3 years ago
I have a felony conviction and likely wouldn’t pass
Pregnancy and Reproductive History
At least one healthy, full-term pregnancy and delivery?
*
Yes
No
Total number of pregnancies
*
Number of pregnancies ending in miscarriage
*
Please Select
0
1
2
3
4 or more
Number of pregnancies ending in abortion
*
Please Select
0
1
2
3
4 or more
Ever had a C-section?
*
Yes
No
Number of C-sections
*
Number of healthy, full-term pregnancies and deliveries
*
Currently pregnant?
*
Yes
No
Estimated due date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Currently breastfeeding?
*
Yes
No
Pregnancy or reproductive complications experienced
*
Endometriosis
Ovarian Cysts
Polycystic Ovary Syndrome (PCOS)
Pelvic Inflammatory Disease
Ectopic Pregnancy
None
Other
Other complications
*
Ever applied to be a surrogate before?
*
Yes
No
Agency or agencies applied to
*
Physical and Mental Health
Current weight
*
Current height
*
Understand and accept BMI requirement
*
Yes
No
Willing to take doctor-prescribed IVF medications, including injections?
*
Yes
No
I’m not sure — I’d like more information
Understanding and willingness regarding hormonal medications
*
Awesome! I get it and am ready.
I still have questions but am open to learning more.
I will not take hormonal medications (this may mean surrogacy isn’t possible).
Diagnosed mental health conditions
*
Bipolar Disorder
PTSD
Severe Postpartum Depression
Eating Disorders
Situational Depression
Major Depressive Disorder
Anxiety Disorder
OCD
Schizophrenia
None
Other
Other mental health condition
*
Ever prescribed medication for these conditions?
*
Yes
No
Currently taking medication for this condition?
*
Yes, currently taking medication
No, stopped
When medication was stopped
*
Please Select
1–6 months ago
6–12 months ago
1–2 years ago
2+ years ago
Medication prescribed for these conditions
*
Diagnosed medical conditions
*
Tuberculosis
Liver Disease
Diabetes
Renal Disease
Cystic Fibrosis
Heart Disease
High Blood Pressure
Asthma
Thyroid Disease
Cancer
None
Other
Currently take prescription medications?
*
Yes
No
Specify prescription medications
*
Relationship and Support
Current relationship
*
Please Select
Married
Widowed
Separated
In a committed relationship and living together
In a committed relationship but living apart
Single
Divorced
Engaged
Other
Partner or spouse name
*
First Name
Last Name
Partner’s feelings about surrogacy
*
Totally supportive and excited!
A bit unsure or has lots of questions
Not supportive at all
Not sure — we haven’t talked about it
Would your partner pass a background check?
*
They have a clean record
They have a minor offense (like a DUI) from more than 3 years ago.
They have a felony conviction and likely wouldn’t pass.
Current child-raising or custody situation
*
I have no children
My children live with me full time
I share custody of my children
My children live with someone else full time
I am currently involved in a custody arrangement
Other
Government assistance received
*
SNAP/food assistance
WIC
Medicaid
TANF/cash assistance
SSI/SSDI
Housing assistance
Childcare assistance
None
Other
Friends or family available to help?
*
Yes
No
Stable home and work schedule for appointments?
*
Yes
No
Lifestyle and Work
Alcohol consumption frequency
*
Please Select
Never
Special Occasions
Daily
Once or twice per week
Once or twice a month
Ever used recreational drugs, including marijuana?
*
Yes
No
Recreational drugs used
*
Marijuana
Cocaine
Heroin
Methamphetamine
Ecstasy/MDMA
Hallucinogens
Prescription drugs used non-medically
None
Other
Other recreational drugs used
*
When recreational drugs were last used
*
Please Select
Less than 30 days ago
More than 30 days but less than 6 months ago
More than 1 year ago
More than 5 years ago
Ever used tobacco or vape products?
*
Yes
No
When tobacco or vape products were last used
*
Please Select
Less than 30 days ago
More than 30 days but less than 6 months ago
More than 6 months but less than 1 year ago
More than 1 year ago
More than 5 years ago
Ever smoked during a pregnancy?
*
Yes
No
Current work situation
*
Please Select
Stay-at-home mom / Not currently working
Part-time
Full-time
Valid driver’s license?
*
Yes
No
Readiness and Interests
How soon would you like to get started?
*
I’m ready now — let’s do this!
I’ll be ready in a few months or longer
Just exploring / learning for now
Referral and Additional Questions
Should we thank someone special for sending you our way?
*
Yes
No
Who can we thank for referring you to us?
*
Anything else to share or ask?
*
Yes
No
Additional thoughts or questions
*
Type a question
Submit
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