Surrogate Assessment

Which best describes you?

SurrogateDonorParent

How did you hear about us?

How did you hear about Surro Blessings? *

Username & password

This creates your private Surro Blessings account. Your password is never shared, exported or shown to staff.

Username *

Password *

At least 8 characters
One uppercase letter
One lowercase letter
One number
One symbol

Contact & basics

Only the questions that apply to your answers appear. Confirmation fields appear once the original entry is complete.

First name *

Middle initial (optional)

Last name *

Date of birth *

Gender *

Citizenship status *

Marital status *

Do you have a valid government ID? *

YesNo

Which country do you currently reside in? *

Start typing to search.

Phone number *

Email address *

Chat ID / username *

Preferred contact method *

Best time to contact *

Time Zone *

We couldn't detect your time zone automatically. Please choose it below.

Search by city or region (for example: Chicago, London, Shanghai).

Preferred language for communication *

Do you speak any other languages fluently? *

NoYes

Do you require a language interpreter for meetings? *

NoYesOther

Emergency contacts (optional)

These contacts are used only if we are unable to reach you directly.

The questions below apply only to your selected role.

What is your reasoning for becoming a Surrogate? *

Are you interested in Doula Services? *

Have you been a Gestational Carrier (Surrogate) before? *

What is your health condition? *

Do you have medical insurance? *

Pregnancy History

How many delivered pregnancies have you had? *

Total pregnancies (including miscarriages and abortion) *

Total number of miscarriages *

Total number of spontaneous abortions *

Total number of therapeutic abortions *

Medical History

Have you been diagnosed with an STD before? *

Have you been diagnosed with any diseases? *

Have you had a blood transfusion? *

Did you have any surgeries in the past? *

Do you have any allergies? *

What is your blood type? *

Are you RH negative? *

Have you had a Pap Smear within the last 12 months? *

Is your menstrual cycle regular? *

Are you currently taking any birth control pills or hormonal contraceptive measures? *

Have you experienced any abnormal vaginal bleeding? *

Are you Hepatitis B immune? *

About You

Would you like to disclose your Race/Ethnicity? *

Height *

Weight *

Calculated BMI

Enter your height and weight to calculate your BMI.

Your BMI is calculated automatically from the height and weight you provided.

Do you have any physical disabilities? *

What is your sexual orientation? *

Do you have any tattoos? *

Do you have any body piercings? *

Are you currently using any illegal drugs or controlled substances? *

Are you currently smoking or vaping? *

Are you currently drinking alcohol? *

What is your major? *

What is your highest level of education? *

Are you employed? *

Have you ever filed for bankruptcy? *

Have you been arrested or committed a crime? *

Have you been involved in any legal cases or any that are pending? *

Have you ever been in a psychiatric facility? *

Have you been in a substance abuse program? *

Do you drive and have your own reliable transportation? *

Is your Driver's License expired? *

Does anyone in the household drink alcohol? *

Does anyone in the household smoke? *

Does anyone in the household currently use illicit drugs? *

Have you ever had any psychological counseling? *

Have you ever been hospitalized for psychiatric illness? *

Are you currently sexually active with anyone other than your partner listed on the application? *

Have you been physically abused? *

Have you ever had thoughts of or attempted suicide? *

Do you currently suffer from anxiety, bipolar disorder, or depression? *

Have you ever experienced any form of depression, including postpartum? *

Please tell us about yourself (for example, hobbies, education, occupation, life story, etc.) *

Photos & Video

Photos

Add up to 5 photos. On a phone you can take a new photo or choose from your library.

Intro video (optional)

Record a new video or choose an existing one.

Spouse / Partner Information

Do you currently have a spouse or committed intimate partner? *

Additional Information

Would you like to add anything else? *

Upload supporting files (optional)

You may add multiple files.

Drug Screen Authorization

By signing below, I authorize the administration of a drug screen and the release of my drug screen results as necessary for program participation, screening, and care coordination.

Will you complete a drug screen if requested? *

Psychiatric Evaluation Authorization

By signing below, I authorize the administration of a psychiatric evaluation and the release of my evaluation results as necessary for program participation, screening, and care coordination.

Will you complete a psychiatric evaluation if requested? *

Medical Release Authorization

By authorizing, you permit Surro Blessings and its designated partners to obtain, use, and share necessary medical information (for example history, labs, genetic screening and infectious disease results) for screening, eligibility and care coordination.

Are you willing to release your required medical information for our services? *

Background Check Authorization

Surro Blessings may obtain consumer reports for screening related to your participation. If you qualify to proceed, a background check will be required. Sensitive identifiers may be provided now or once you qualify.

Are you willing to undergo a background check? *

Appointments

You're almost there! Let's get a head start on your next steps.

When was your most recent Pap Smear?

Within the last 12 monthsMore than 12 months agoI'm not sureI have never had a Pap Smear

Have you scheduled an appointment with your OB/GYN for your OB Clearance Letter and/or Pap Smear?

YesNot YetI Need Assistance

We recommend scheduling your appointment as soon as possible, ideally within the next 7 days. This is about scheduling the appointment — the date your provider has available may be later, and that's completely fine. An appointment is not required to begin or submit your assessment.

Transportation & Appointment Support — this helps us remove barriers to your appointments. It never affects your eligibility or your matching.

Follow-up availability — let us know when it's easiest to reach you.

Preferred follow-up date

Earliest time

Latest time

Preferred contact method

Follow-up notes

Terms & Acknowledgements

Please review and confirm each acknowledgement below.

I affirm that all information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that the information provided will be used solely to determine eligibility and participation, and may be shared only with authorized personnel and as required by law.

I acknowledge that I am completing this assessment voluntarily and of my own free will.

I have read, understood, and agree to the terms of each agreement and authorization that I personally completed or signed in this assessment.

I agree that Surro Blessings may contact me regarding my assessment, account, journey, appointments, requests, opportunities, and related services using the contact information I provide.

I agree to receive text messages from Surro Blessings at the mobile number I provided regarding my assessment, account, appointments, journey updates, opportunities, support, and related services. Message and data rates may apply. Consent is not a condition of purchase. I understand I can opt out of text messages as described in the SMS Terms.

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Your privacy matters. The information you provide helps Surro Blessings support your journey, coordinate relevant services, and connect you with appropriate opportunities and partners when applicable. We handle your information with care and use or share it only as appropriate for these purposes and as described in our Privacy Policy.

Surrogate Assessment

Which best describes you?

How did you hear about us?

Username & password

Contact & basics