You are Needed

If you are approaching our site in order to become a surrogate, let us take this time to thank you. Helping a childless couple become a family is a truly generous gift. We applaud you considering surrogacy. Surrogacy is an option that infertile couples are very uneasy about. Each couple wonders how they can be sure their surrogate will follow all her doctor’s instructions, abide by the terms in the contract, and if she will give them their child. You already know of the joys that being a parent brings, and the fact that you are contemplating becoming a surrogate defines what a caring and compassionate person you are.

We are here to guide you through the process. As a surrogate mother, you have the opportunity to find out about the couple's history, their infertility struggles, if they already have children, if they would like more than one child, their likes and dislike, their personalities, etc. You will also meet the couple prior to determining if this is the couple you would like to work with.

The entire process of becoming a surrogate usually takes several months. You are beginning the first stage by completing the initial application below. If you would prefer to fill this initial application on paper, you can click on the link below and one of our staff members will send you an application via regular mail and you can return it at your convenience.

sarahaguiar@littleblessingsinc.com

Confidential Information

(This information will not initially be disclosed to the couple. Only a first name will be given until the selection process is completed. At that time only last names, phone numbers and addresses will be disclosed. Social Security and drivers license numbers will never be disclosed.)

Please take your time and complete the form below.

Enter information into the fields below.
All fields are required.

First Name: MI: Last Name:

Address: City :

State: Zip:

Age:

Date of birth:

Home Phone: Cell Phone: Work Phone:

Do you currently work? Yes No

If yes, what is your position?

Would you be able to take time off work if needed? Yes No

May we leave a message at either work or home?Yes No

Best time to call? Morning Afternoon Night

Email Address:

Referred By:

What is your motivation for wanting to become a surrogate?

Support System: ("What would your family think of you doing this"...etc.)

How long have you been interested in being a surrogate?

Married?Yes No

Husband's name How long have you been married?

Single?Yes No

Who are you living with?

Other person(s) in the household's name?

Divorced?Yes No

How Long?

Children?Yes No

Ages? Birth Weights? Full TermYes No

How was your pregnancy, labor and delivery?

Were there any complications?

Abortions?Yes No

Age at time?

Miscarriages?Yes No

Age at time?

Height? Weight?

Hair? Eyes? Complexion?

Ethnic Background?

Religion?

Education? Occupation?

Smoke?Yes No

Amount Daily? Will you quit?Yes No

Illegal drugs?Yes No
Prescribed Medication?

Birth Control?

Allergies?

Blood type?

Medical Insurance

Hospitalized (operations/illnesses)?

Do you have transportation?Yes No

If not, how do you intend to keep doctor's appointments?

Health History (family member that carries gentic illness and age it was discovered)

Age Mother: Illness:

GrandMother: Illness:

GrandFather: Illness:

Age Father: Illness:

GrandMother: Illness:

GrandFather: Illness:

Brother: Illness:

Sister: Illness:

Children: Illness:

Any other illness which are carried withen your family?