Support Enquiry To help us understand your situation and journey to date, please complete this enquiry form. Once submitted, a Growing Families staff member will be in contact via email or phone to discuss how we can best assist you. We will review your unique circumstances and discuss how we can support you. This initial call is a free service and all information you provide is strictly confidential 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 do you plan to have a child? ---Within a yearWithin 2 yearsWithin 3 yearsMore than 3 years Does your family building require an Egg Donor? ---YesNoUnsure Does your family building require a Surrogate? ---YesNoUnsure 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) ---< $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
