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  • Surrogate Application

    Please take a minute to answer the following questions as it will give us a good idea of where to begin.

  • This form will cover the following:

    • Personal Contact Information
    • Relationships and Support System
    • Health and Medication
    • Pregnancy Details
    • Lifestyle
    • Current Health
    • Surrogate Requirements

    If you have any questions, please feel free to call or text our main business line:

    208-996-3648

    Or Our Surrogate Intake Coordinator Natasha 208-319-4985

     

     

  • Personal Contact Information

  • Birth date*
     - -

  • Relationships and Support

  • Relationship Status*

  • Do you live with your partner?

  • Does your spouse/partner support your decision to become a surrogate?

  • Health and Medication

  • COVID-19 status
  • Are you taking prenatal vitamins?*
  • Are you taking anti anxiety or depression medications?*

  • Pregnancy Details

  • I have given birth to and am raising/have raised at least one child*
  • Have you been a Surrogate before?*
  • Rows
  • Rows
  • Delivery Method
  • Have you had any previous pregnancy complications?*
  • Have you ever had or have an STD?*

  • Lifestyle

  • Primary form of Transportation*

  • Are you a US citizen?*
  • Do you, or have you ever had any misdemeanors or felonies other than minor traffic violations? *
  • Do you have Life Insurance?*
  • Are you receiving any state or federal financial assistance (Childcare assistance, Medicaid, Food-stamps, housing assistance, etc)?*

  • Current Health

  • COVID-19 Info

  • Date of Vaccination or Illness:
     - -
  • Date of Vaccination or Illness:
     - -
  • Date of Vaccination or Illness:
     - -

  • Please note that Abundant Life requires drug and nicotine screening throughout screening and pregnancy.

  • Nicotine Use. (Please check all that apply)*

  • Do you understand you will need to abstain for a minimum of 6 months before acceptance into the program?

  • Recreational drug use (please check all that apply)*
  • Do you understand that you will need to abstain from all recreational drug use during your screening and pregnancy?
  • Does your Spouse/Partner use any form of nicotine?
  • Alcohol and Drug abuse*

  • Surrogate Requirements

  • Is this your first time being a Gestational Surrogate?*
  • Have you ever met anyone who has been a Gestational Surrogate, or formed their family through surrogacy?*

  • Abundant Life Surrogacy supports and ADVOCATES for all family types including but not limited to:

    • LBGTQ+
    • Single Parents
    • International Families
    • Multiracial Families
    • ALL races, religions and creeds.
  • If you have personal prejudice or moral objections to any of these family dynamics we will not be able to accept you into our program.*

  • I understand as a surrogate candidate, both myself, and my husband/partner, will meet with a licensed mental health professional for a psychological evaluation.*
  • Are you willing to consent to a full medical examination which will include a vaginal ultrasound, pelvic examination, communicable disease testing, and drug testing.*
  • Are you comfortable taking medication to prepare your uterus for implantation and to help maintain the pregnancy? This medication may be in the form of a pill, a patch, a vaginal suppository, or an injection. *
  • I understand I must act responsibly, and understand that the intended parents will depend on me to follow medical instructions, and to take care of myself emotionally and physically.*
  • How would you like us to contact you? *

  • Should be Empty: