SMC Questionnaire

Thank you for your interest in SMC!
Before you join, please take a moment to answer a couple of questions.
Please contact us if you need any assistance.

All information is confidential for our internal use only, and will not be shared with any other organizations.

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First Name

Last Name

Your Email

Street

City

State/Province

Zip/Postal Code

Country

Phone

Check here if you are a woman.

Are you a woman who is
 Thinking about having a child? Attempting to become a single mother? Pregnant? A single mother by choice? A mother in another way? Interested in the subject of single mothers? Other (please specify)

What is your marital status?
 Never Married Divorced Widowed Other (please specify)

Are you going to be co-parenting with anyone at the outset?
 No Yes

Any additional comments: