Support Enquiry So we can best advise you, we require specific information regarding your individual circumstances. All information provided is kept strictly confidential. We collect information on things like marital status, household income, nationality and medical conditions so we can provide services customised to your situation A Growing Families staff member will be in contact via email or phone to discuss how we can best assist you. A follow up paid consultation is often required to provide professional advice to support your unique circumstances. This advice may include problem solving, program eligibility, wait times, costs, legal and parentage issues, embryo creation advice, donor issues, agency or IVF clinic recommendations, risks and how to avoid them. Person One The Person completing this form Gender —Please choose an option—MaleFemaleOther Date of birth AustraliaAustriaBelgiumBulgariaCanadaChinaDenmarkFinlandFranceGermanyIndonesiaIrelandIsraelItalyJapanKorea, SouthNetherlandsNew ZealandNorwayPolandPortugalSingaporeSpainSwedenSwitzerlandTaiwanUnited KingdomUnited StatesOther – Asia & PacificOther – EuropeOther – Middle EastOther – AfricaOther - South & Central America 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 —Please choose an option—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 —Please choose an option—MaleFemaleOther Date of birth Is Residential Address of Person Two the same as Person One ? —Please choose an option—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 do you plan to have a child? —Please choose an option—Within a yearWithin 2 yearsWithin 3 yearsMore than 3 years Does your family building require an Egg Donor? —Please choose an option—YesNoUnsure Does your family building require a Surrogate? —Please choose an option—YesNoUnsure Do you have Embryos? —Please choose an option—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) —Please choose an option—< $79 999$80 000 - $139 999$140 000 - $179 999$180 000 + Which of the following applies to you ? I would like general adviceI have a specific question I need answeredI just need an introduction to reputable providersI want to learn more before I make a decisionI need advice on shipping embryos / eggs / spermI would like Concierge support How did you hear about us?Social MediaGoogleWord of mouthAdvertisementDoctor/nurse/counsellor referralGrowing Families facebookSurrogacy forumOther 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
