Guest Application

1
Which statement best describes your purpose for applying?* This field is required.
Actively trying to conceive.
Just preparing to try for a baby in the future.
Not planning to have a baby, just interested in natural reproductive health.
2
This group is only for women, and you must be over 18. What is your age?* This field is required.(Men have a separate group and application.)
18-25
26-33
34-41
42-49
50+
3
Which best describes your perspective on fertility?* This field is required.
It is mostly determined by genetics; it's basically the cards you were dealt.
It is highly influenced by lifestyle & environment; it can change throughout time.
4
Which best describes your perspective on healthcare?* This field is required.
There is value in natural medicine & the wisdom of ancient traditions.
Modern western medicine always knows best.
5
Choose ALL the statement (s) that apply to your fertility journey.* This field is required.
We've been actively trying for months/years now.
We plan to start trying in the next couple years.
We're kind of trying...we're not "preventing."
I've been pregnant at least once.
I've had at least one miscarriage.
I've had at least one live birth.
6
Select ALL the statements that usually apply to your cycle.* This field is required.
Clots in the blood
Short cycles (less than 26 days)
Dark red or brown blood
Long cycles (more than 30 days)
Spotting outside of the period
Irregular cycles (I never know!)
I only bleed for 1-2 days
I bleed for a week or longer
I think I'm ovulating midcycle (ish)
I don't know if or when I'm ovulating
None
7
Have you received or do you highly suspect any diagnoses related to fertility?* This field is required.(You'll have the chance to give detail on the next question.)
Yes, I have.
Yes, my partner has.
No, we've been checked out and have no abnormal findings.
No, but we haven't been checked out yet.
8
Please explain any abnormal findings, diagnoses, or details from the previous few questions that you think are important to include about your situation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Have you ever been in a fertility group before?* This field is required.Facebook, etc.
Please Select
Please Select
Yes
No
10
What did you like or not like about that experience?* This field is required.
11
What are the top 2-3 things you'd like help or improvement with related to fertility?* This field is required.("getting pregnant" "staying pregnant" "regular periods" "better egg quality" "less PMS" etc)
Huge
Large
Normal
Small
Ok
Ok
12
What have you already tried to improve periods, hormones, or fertility? Please list these therapies, treatments, supplements, exercises, coaching, diets, etc.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Where did these things fall short for you? * This field is required.Too difficult? Too expensive? Too slow? Unable to measure change?
Huge
Large
Normal
Small
Ok
Ok
14
What do you feel is your biggest challenge in improving your fertility right now?* This field is required.(What's standing between You and Fertile You?)
Huge
Large
Normal
Small
Ok
Ok
15
What are your worst fears about your fertility? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
16
How do you want to feel about the direction of or next steps on your fertility journey?* This field is required.
17
If you had to choose one, would you rather:* This field is required.
Get pregnant ASAP, no matter what.
Get pregnant in a few months, knowing I've learned about my body, what it needs to be healthy and fertile, and how to keep it that way for good.
18
What question would you most like answered about your fertility? * This field is required.
19
What do you hope or expect to gain from joining the Cultivate Fertility Group?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Name* This field is required.
First Name
Last Name
21
Email Address* This field is required.This is how we we contact you if your application is APPROVED. Please be sure to check your SPAM/JUNK folder regularly to see if you have been approved.
example@example.com
22
What country do you live in?* This field is required.(We are based in the US, and certain herbs recommended might not be available where you are.)
23
How did you hear about Dr. Juli or Cultivate Fertility?* This field is required.
24
Which fertility video/post caught your interest?* This field is required.
25
If accepted to the group, you must read, agree to, and follow all rules & conditions provided there regarding manners and privacy. By joining and remaining in the group, you are confirming that you have read that information and agree to it. If you do not follow the rules & conditions, you will be removed. Do you agree?* This field is required.
YESNO
26
Do you understand that your Approval email will likely be hiding in your Junk/Spam email folder?* This field is required.Be sure to check it regularly!
YESNO
Should be Empty: