Lumière Surrogacy Advisory – Intended Parent Application Form

This application helps us understand your unique journey and determine if our services align with your needs. We only work with a select number of clients at a time to ensure the highest level of service and success. Please provide detailed and honest responses.

Section 1 - Personal Information

First name

Last name

Email

Phone

Address

Your Partner's Information (if applicable)

First Name

Last Name

Email

Phone

Section 2 - Relationship Details

Are you applying as:

Single intended parent

A couple (Please provide both names above)

What best describes your current family structure? (e.g., LGBTQIA+ couple, heterosexual couple, single parent, blended family, etc.)

Do you have children already?

Yes

No

Section 3 - Surrogacy Journey

What led you to consider surrogacy as a family-building option?

Are you working with a surrogacy agency or independently?

Agency

Independant

Currently exploring options

Do you have embryos created?

Yes

No

If yes, How many and what clinic are you working with?

Briefly describe your fertility story so far: (miscarriages, IVF attempts, etc. Share what you’re comfortable with.)

Section 4: Your Vision for Parenthood

What qualities are most important to you in a surrogate match? (e.g., communication style, values, lifestyle, location, etc.)

What do you want your future child(ren) to know about how they came into the world? (Open text)

Do you feel confident telling your story on camera or in writing?

Yes

No

Open, but nervous

Are you comfortable sharing aspects of your story online to reach more surrogates?

Yes

No

Open to guidance

Section 5: Media & Scheduling

Preferred Package:

Lumiére Profile Audit *$1,500

Lumiére Media Package *$3,000

Hourly Consult *200/HR

Do you have a profile already created (PDF or agency format)?

Yes (Please upload)

No

Do you have personal media (photos or videos) that help tell your story?

Yes

No

Needing help with this

Section 6: Final Notes

Is there anything else you'd like us to know before we connect?

How did you hear about Lumière Surrogacy Advisory? (e.g., Instagram, referral, surrogacy group, Google search)

Upload current profile