Brussels 2018 Consultation Request Form

Individuals who already registered for our Brussels 2018 Conference may use this form to request a private consultation with one or more providers who will be available before and following the conference on September 22-23 2018.

Your information will remain confidential and only shared with the service providers you indicated (but first you will receive a confirmation email to verify that you indeed submitted this request).

1. Prospective parent #1Please provide full legal name.

First Name *This question is required.

Last Name *This question is required.

Birth date *This question is required.

calendar

City

State (USA or Canada)

Zip / postal code

Country *This question is required.

Email Address *This question is required.

Phone number *This question is required. This question requires a valid email address.

Do you identify as: *This question is required.

2. Do you plan to have children as: *This question is required.

Prospective parent #2 *This question is required.Please provide full legal name

First name

Last name:

Birth date

calendar

Are you legally married?

With which of the following agencies and / or clinics would you like to request a private consultation? *This question is required.* Asterisk denotes a member of the MHB Advisory Circle

How did you have your previous children (check all that apply)?

Adoption / foster care
Surrogacy
Co-parenting
Other Please enter an 'other' value for this selection.

If you already have children through surrogacy, don't forget to fill our MHB Parent survey!

4. What type of surrogacy are you pursuing / considering?

5. Languages you (or your partner) speak:

Portuguese
Chinese
Hebrew
Other Please enter an 'other' value for this selection.

6. Do you have any other comments you want to share with the service providers?

Brussels 2018 Consultation Request Form

Part 1: Personal details