About Expect Miracles Surrogates:

Our Surrogates:

They are mature, stable, self-aware women that have made a decision that surrogacy is an experience they would like to participate in. They are self-sufficient, team players, that are confident, assertive, active, and optimistic. They believe that being a surrogate will give them a sense of accomplishment by making a difference in the world and that by participating in surrogacy they can make a unique personal contribution to another family.

Their Prerequisites:

They need to currently have a stable home life and a positive health history both in previous pregnancies and in general. Additionally, they need to be emotionally equipped to care for the pregnancy and child as they would in any long term childcare situation without forming a parental bond.

Their Screening:

The screening and selection procedures are strict as surrogacy is commercial and subject to professional regulation. Screening includes in depth interviews, background checks, medical approval by her OBGYN, medical records and physical exams performed by chosen qualified IVF physicians.

Their Background:

Our Surrogates come from stable homes with supportive families and friends. They have found pregnancy to be pleasurable, they feel skilled and confident about participating in a surrogacy arrangement.

Their Confidence:

Our surrogates are highly confident from the start about the medical process, their ability to look after the well being of the baby and the birth. They make their decisions with informed consent, an understanding of what the surrogacy arrangement requires and a confidence that they can carry through with their initial decision to participate in Surrogacy.

Their Reasons:

They come to these arrangements on their own terms with a sense of empowerment wanting to do something special and unique with their life.

Their Relationship with Intended Parents:

The quality of the surrogate's relationship with the Intended Parents during and after the pregnancy determine the surrogates satisfaction with the experience. Our surrogates want to be treated with respect, honor and trust. Good communication combined with a high level of honesty and trust between surrogates and Intended Parents are necessary for the relationship to work.

Their Accomplishment:

In the end they are filled with pride and accomplishment of completing another family.

Surrogate Pre-screening Information

This survey helps Expect Miracles Surrogacy pre-screen candidates and learn about you.

How did you find us?:
Have you given birth to at least one child that you are raising?:
Are you an experienced surrogate?:
Age, Date of Birth:
Do you use antidepressants or tobacco?:
Do you have any history of illegal drug or alcohol abuse?:
Have you ever had a C-section? If yes, how many have you had?:
Height:
Weight:
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Do you drive?:
Do you own a car?:
Are you a U.S. Citizen?:
What language(s) do you speak?:
Do you have medical insurance?:
If yes, do you have this policy through your employer or your spouse/partner's employer?:
Name of health insurance company:
What is your yearly deductible?:
What is your coverage percentage?:
What is your co-payment? ($/per office visit):
What is your monthly payment?:
What is your maximum out-of-pocket expense per year?:
Does your medical insurance include maternity coverage?:
Do you have medical insurance without a Surrogacy Exclusion?:
For a transfer, are you open to travel?:
Are you currently employed?:
If yes, what is your current occupation/position?:
How many days and hours per week do you work?:
What days of the week do you work and what are the hours?:
What is your income? Please list hourly or salary wage:
Does your employer provide short term disability?:
If yes, what is the percentage covered?:
At how many weeks off does coverage begin?:
Current marital/relationship status:
If married, what is the date of your marriage?:
If you have ever been divorced, what is the date of divorce?:
If unmarried, but in a relationship, how long have you been with your partner?:
Does spouse/partner drive?:
Spouse/partner's current occupation/position::
What days of the week does spouse/partner work, and what are the hours?:
What is the spouse/partner's income? (Please list hourly or salary wage):
Has spouse/partner ever been prescribed psychiatric medication(s)?:
If yes, please list dates and explain:
Has your spouse/partner ever been hospitalized due to a psychiatric issue?:
If yes, please list dates and explain:
Has there ever been domestic violence in your home?:
Do you or your spouse/partner have any legal claims/cases pending at this time?:
Been convicted of a felony?:
Been accused and/or convicted of child or spousal abuse?:
Lost custody of a child?:
Been turned down by an adoption agency?:
Been in a substance abuse program?:
Been arrested or had conflicts with the law (including DUI arrests)?:
Have you ever been a surrogate?:
Have you ever been an Egg Donor?:
How many times have you been pregnant?:
How many children (natural) do you have?:
How many adopted Children do you have?:
Please list their gender, birth dates, and months it took you to conceive:
Do any of your children have physical health problems?:
Have you ever placed a child for adoption?:
Are you currently breast feeding?:
Have you ever delivered a premature baby?:
How many weeks gestation was/where the baby(ies)?:
Have you ever had a miscarriage?:
How far along where you in the pregnancy?:
Have you ever had any pregnancy and/or delivery complications (i.e. pre-term labor, high blood pressure, gestational diabetes, placenta, etc.)?:
Have you ever had a c-section?:
If yes, when? (Please list all pertinent dates)::
If yes, what was the reason for your c-section(s)?:
When did your last period begin and end?:
Do you have regular menstrual cycles?:
How long does your monthly cycle typically last?:
What method of birth control are you using at this time?:
How long have you been on the form of birth control?:
When did you last see your OB/GYN?:
When was your last pap smear?:
What were the results of your last pap smear?:
What is your blood type?:
Have you ever suffered from severe depression?:
If yes, please list dates and explain::
Have you ever been prescribed psychiatric medication(s)?:
If yes, please list dates and explain:
Have you ever been hospitalized due to a psychiatric issue?:
If yes, please list dates and explain:
Please describe your diet in general (i.e. if you are a vegetarian/vegan, what type of food do you eat regularly?:
Do you exercise?:
If yes, how often, and what type of exercise specifically?:
Have you ever had an eating disorder?:
If yes, please explain:
Have you ever been hospitalized or had a major illness?:
If yes, please explain:
Have you ever had surgery (minor or major)?:
If yes, please explain:
Do you have any chronic medical conditions/problems?:
If yes, please explain::
Do you smoke cigarettes?:
If yes, how often?:
Have you smoked any form of tobacco within the past three years?:
If yes, please list if it has only been once or a few times.:
Does anybody in your home smoke cigarettes or any other tobacco products?:
Do you drink alcohol?:
If yes, how often?:
Do you use illegal drugs?:
If yes, please explain::
Have either you or your spouse/partner ever been diagnosed with any of the following STD's? Hepatitis B, Hepatitis C, HIV, Herpes, or Other?:
Have you ever been a Surrogate or an Egg Donor?:
If yes, please specify (surrogate, Egg Donor, or both):
If yes, please list all pertinent dates:
What was the outcome?:
Please describe your feelings surrounding your surrogacy and/or egg donation experience(s):
Have you discussed your plans to become a Surrogate with your spouse or partner if applicable?:
If yes, what was the reaction/response?:
Who will support you emotionally throughout and after your Surrogacy experience?:
Please describe the "ideal" couple/individual for whom you would like to be a Surrogate:
Are there any circumstances which would cause you to NOT want to work with a couple or individual?:
Why do you want to be a Gestational Surrogate? (Please explain in as much detail as possible.):
Please tell us about yourself! Describe your personality, character, interests, and hobbies::
How do you think you will feel, on an emotional level, carrying and delivering a baby that will not be your own? How can we (and you Intended Parent(s)) be certain that you are not going to form a "maternal" attachment to the baby or babies you are carrying as a surrogate? We recognize Surrogates typically care deeply for the baby (ies) they are carrying and feel a strong sense of responsibility to ensure the baby (ies) is/are brought safely into this world. However, it is most important that they do not form a "material" attachment that will cause them to experience emotional issues or regrets. Please explain:
How much contact would you like with your Intended Parents throughout the pregnancy?:
Are you willing to sign a HIPAA release form for the Intended Parents and Agency to be allowed to receive medical information pertaining to the baby (ies)?:
How would you feel about the Intended parents joining you at these doctor appointments, and potentially being present in the doctor's office during ultrasounds and such?:
Would you be comfortable with the intended Parents being in the delivery room when their baby (ies) is/are born?:
Please expand, if you wish, on anything specific you envision during the birth experience:
Please write a short note to your Intended Parents:
Oftentimes, the reproductive endocrinologist will transfer 2-4 embryos in order to increase the likelihood that a pregnancy will occur. Because of this, it is possible that you could become pregnant with multiples (two or more babies). How would you feel about carrying twins?:
How would you feel about carrying triplets?:
If it is confirmed that you are carrying triplets or more, and the Intended Parent(s) choose to reduce (in order to increase the chances of a healthier pregnancy) would you be willing to do so?:
What if it is confirmed that the baby has a serious medical condition and the Intended Parents choose the option of early termination? Would you be willing to accommodate their wishes? (Keep in mind, this determination would likely be made sometime around 12-16+ weeks).:
If requested by the Intended Parents (and/or recommended by the OB) would you be willing to have an amniocentesis?:
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