Fertility Consultation

Fertility Consultation

What is your name?

First NameLast Name
What is your best email address?*
example@example.com
What is the best number to reach you on to schedule your appointment*

Country CodeArea CodePhone Number
What time of day do you prefer your appointment*

Early Morning (EST)Late Morning (EST)Early Afternoon (EST)Afternoon (EST)Evening (EST)

How long have you struggled to get pregnant?**

Up to 1 Year2 Years3 or more years

Have you ever tried IVF or IUI? *

YesNo

Explain Your Experience with IVF or IUI

Please explain other

Have you experienced any of the following*

Emotional TraumaMiscarriageRapeLoss of a ChildAbortionAdoptionChildhood TraumaNone of the Above

Does the doctor tell you:*

You should be able to get pregnantYou cannot get pregnantYou have unexplained infertilityI have not seen a doctor yet!

Do you have a regular period? (ovulation)*

YESNoIrregularNot in over a yearOther

Has the doctor told you that you cannot conceive naturally*

YesNo

Explain what the doctor has told you

Do you have / or experienced*

Trauma Block[s]Mindset Block[s]Emotional Block[s]Mistrust Block [s]Other Block [s]

Have you been diagnosed with a mental health issue?*

YesNo

Please explain your mental health:

Do you have children of your own?*

YesNo

How many "live" births have you had?

Do you have a husband or significant other to support you on this journey?*

YesNoNo, I am happy to start a family as a single mom

On a scale of 1-to-10 How ready is your husband/significant other to invest in a Body-Mind Fertility Program with you?*
10 = he is super ready & supports me in my choices!

Are you open to Holistic approach to getting pregnant? (Mind, Body and Soul)*

YesNo

Have you taken any of Saskia's programs?

YESNot Yet

What program(s) have you done?

Describe your Fertility Journey*

On a scale of 1-10 how ready are you to Get Pregnant?*

Why do you think fertility coaching with Saskia can help you get pregnant now?

Which of these are you interested in...*

Private Fertility CoachingGet Pregnant Now Foundation ProgramHigh-End Private Fertility Coaching with Saskia ONLYNone of the above, I just have questions about my fertility challenges

What are your questions about the Get Pregnant Now Program?*

Are you committed to invest money right now in Saskia's Get Pregnant Now Program?*

Yes. Absolutely!Yes, but in Private Coaching OnlyNo, there is no way I can afford itMaybe, after my questions are answeredMaybe, but I have a lot of doubts

What is your annual household income:*

under $30,000$30,000 to $50,000$51,000 to $70,000$71,000 to $100,000$100,000 to $150,000$151,000 to 250,000$250,000 +

Who can we thank for referring you?*

Where is Lead From

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I agree to be contacted regarding this application to explore my options

Yes
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