Eligibility Screen
This short questionnaire helps us determine whether the Fertility Foundations program is the right fit for you. It takes about 2 minutes to complete.
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently pregnant?
*
Yes
No
Are you actively trying to conceive right now?
*
Yes
No, but planning in the next 3 months
Planning in 3–6 months
Planning in 6–12 months
Not planning pregnancy
Are you currently undergoing fertility treatment (IUI, IVF, ovulation induction)?
*
Yes
No
Do you have any uncontrolled or complex medical conditions? (Examples include uncontrolled diabetes, active autoimmune disease, eating disorder, or major psychiatric illness.)
*
Yes
No
Not sure
Have you ever experienced any poor pregnancy outcomes? (This information helps us determine whether additional clinical review or support may be helpful. It does not affect eligibility.)
*
No
Yes - miscarriage
Yes - stillbirth
Yes - preterm labor
Other
Are you willing to complete recommended lab testing as part of this program?
*
Yes
No
Are you comfortable participating in group education and support sessions?
*
Yes
No
What best describes what you’re looking for?
*
I want to optimize my health before pregnancy
I’ve been trying and want deeper insight and support
I want urgent fertility treatment
I want a guaranteed pregnancy outcome
Are you willing to invest the time and effort required for a 12-week program?
*
Yes
No
The program fee for Founder's Cohort: $1,500 (future cohorts will be $2,500.) Clinical visits and laboratory testing are billed separately through insurance when applicable. This fee reflects the depth of clinical expertise, coordinated care, and structured education provided throughout the program.
*
I understand and am comfortable with this
This does not work for me
We recognize that cost can be a barrier to care for some individuals. While maintaining the clinical quality and integrity of this program, limited financial access options may be available. Which best describes your situation? (Check all that apply)
*
I am able to pay the program fee in full
I would need a payment plan to participate
I would like to be considered for a sponsorship or scholarship
I am not able to participate financially at this time
I understand that this program does not guarantee pregnancy outcomes and is not a replacement for fertility treatment when indicated.
*
I agree
I do not agree
Submit
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