Please complete the situation assessment form so we can understand your journey to date. Once completed, a Growing Families staff member will be in contact to arrange a complimentary 15-minute consultation call. During this call we will discuss your unique circumstances, explain your family building options, and explain how we can support you throughout your journey. Please complete the below form Person One The Person completing this form Gender ---MaleFemaleOther Date of birth Pre-existing medical conditions EndometriosisKidney DiseaseMRKHUnexplained infertilityReproductive lossHigh risk past pregnanciesHysterectomyAsherman's SyndromeAuto-immune disorderMedical treatment for cancerHypertensionDeformation of uterine cavity or cervixHIV+NilOther Marital Status ---Male - Single / divorced / separatedFemale - Single / divorced/ separatedSame sex male couple - Married / De-factoSame sex female couple - Married / De-factoHetero couple - marriedHetero couple - unmarried / De-facto Person Two Singles need not complete this section Gender ---MaleFemaleOther Date of birth Is Residential Address of Person Two the same as Person One ? ---YesNo Pre-existing medical conditions EndometriosisKidney DiseaseMRKHUnexplained infertilityReproductive lossHigh risk past pregnanciesHysterectomyAsherman's SyndromeAuto-immune disorderMedical treatment for cancerHypertensionDeformation of uterine cavity or cervixHIV+NilOther General Questions Please answer the following questions to enable us to provide the support / next steps you need. When would you like to have a child? ---Within a yearWithin 2 years from nowWithin 3 years from nowMore than 3 years from now Do you require an Egg Donor? ---Yes - already have oneYes - but don't have oneNoUnsure Do you require a Sperm Donor? ---Yes - already have oneYes - but don't have oneNoUnsure Do you require a Surrogate? ---Yes - already have oneYes - but don't have oneNoUnsure Do you have Embryos? ---YesNo If applicable, how many embryos are there and where are these being held? (Clinic name & location) Which of the following best describes your household income (note please include both Person One and Person Two) ---< $40 000$40 001 - $59 999$60 000 - $79 999$80 000 - $99 999$100 000 - $119 999$120 000 - $139 000$140 000 - $159 999$160 000 - $179 999$180 000 + Which of the following applies to you ? I am new to this and need advice & supportI have a specific question I need answeredI’d like a 15 minute phone discussion upfrontI know which country I am engaging in and just need an introduction to reputable providersI want to learn about costs / timeframes / legal issues / logistics / paperwork / eligibility options before I make a decisionI need help with shipping embryos / eggs / sperm How did you hear about us?Social Media (Facebook, Twitter)GoogleFriendsAdvertiseOthers Thank You. We will be in touch shortly to help you further. Please opt me in to receive the Growing Families Newsletter & occasional informative updates
