Surrogacy Pre-Qualification Application

Surrogacy Pre-Qualification Application

Please fill each question out with as much information as you can provide. Please be open and honest. We will contact you after we review your pre-qualification application. If you have any questions, please call Alisha or Nicole at 208-297-5189 or email us at surrogacy@hostofpossibilities.com
General Information
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Age *
What is your height? *
Your current height and weight is important in determining your BMI.
What is your current weight? *
Your current height and weight is important in determining your BMI.
Are you a U.S. citizen?

Yes No
What city do you live? *
In what state do you live? *
Do you work outside the home? *

Yes No
How did you hear about us? *

Craigslist FindSurrogateMother.com Google Referral Facebook
Family
Relationship Status (please select all that apply) *

Married Divorced Single Live-in Partner Dating
How many pregnancies have you had resulting in a live birth? *
How many pregnancies have you had resulting in a miscarriage, or still birth? *
How have your pregnancies been: full term? vaginal? any C-sections? any complications? *
What is your current method of birth control? *

Pill IUD Patch or Shot Tubal Litigation Partner has Vasectomy Abstinence
Date of last PAP: *
American Society for Reproductive Medicine Guidelines

Please answer truthfully to all questions. Just because you answer yes to one question doesn't mean you will be disqualified. It's more important that you are open and honest with all your answers.
Do you have health insurance? *

Yes No
Are you on any state assistance (food stamps, section 8 housing, Medicaid)? *

Yes No
If you are on state assistance, please list what you receive:
Do you and/or your partner have a criminal background (misdemeanors, felonies, arrests)? If yes, please explain. *
Do you have any pre-existing medical conditions that you have every been diagnosed with? If yes, please explain. *
Do you take any prescription medications on a daily basis? If so, please list the name and dose of the medication. *
Have you ever been treated by a Psychologist for any psychological disorder (including but not limited to: depression, anxiety, PTSD, bipolar, etc.)? If yes please explain: were you officially diagnosed? at what age? are you taking medication? *
Have you ever been treated for drug or alcohol abuse? *

Yes No
Do you currently smoke? *

Yes No
If you smoked in the past, did you smoke during your pregnancies?

Yes No
Does your partner currently smoke?

Yes No
Do you have reliable transportation to get yourself to and from medical appointments? *

Yes No
Preferences

We have a wide variety of couples and individuals looking to start their family with your help. Please think about who you would be comfortable carrying for. (If you qualify, you can always change your mind later.)
Would you carry for a...(please select all that apply) *

Heterosexual Couple Same Sex Couple Single Dad Single Mom International Couple or Individual
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Surrogacy Pre-Qualification Application

General Information

Family

American Society for Reproductive Medicine Guidelines

Preferences