Conception Connection Assessment Meeting
- I / We would like to schedule a consultation to discuss my/our participation in the Conception Connection Registry and/or Counseling Service (check all that apply):
- ___ Tuesday between 8:00 a.m. and 1:00 p.m.
- ___Thursday between 8:00 a.m. and 1:00 p.m.
- ___Monday between 6:00 and 8:00 p.m.
- ___Wednesday between 6:00 and 8:00 p.m.
- ___ I / We live in the Greater Boston Area and will meet with you in person.
- ___ I / We do not live in the Greater Boston Area and would prefer to meet with you by telephone.
- My / Our name(s) is (are):
- ________________________________________________________________
- ________________________________________________________________
- Email address(es)________________________________________________________________
- Day phone_____________________________________________________________________
- Evening phone__________________________________________________________________
- Postal addresss_________________________________________________________________
- I was / We were referred to AFM by:
- ___word of mouth
- ___web
- ___ad
- ____________________________ article in publication
- AFM will contact you by email or phone within 48 hours of receiving this form to suggest specific dates and times and to provide you with directions to our office.