Fertility Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How long have you been trying to conceive?
3 month
6 month
year
2 years
more than two years
Have you been pregnant before? (Y/N)If yes, please share details (live birth, miscarriage, termination, etc.):
Are you currently undergoing or planning any fertility treatments (e.g., IVF, IUI, acupuncture, supplements)?
Have you received any medical diagnosis relating to fertility (e.g., PCOS, endometriosis, unexplained infertility)?
Have you ever experienced any pregnancy fears,scares, or trauma?
How do you currently feel about your ability to conceive?
Confident
Hopeful
Neutral
Doubtful
Hopeless
Have you ever linked negative emotions (fear, shame, guilt, trauma) to pregnancy or motherhood?
YES
NO
Unsure
Do you notice any recurring negative thoughts about fertility, pregnancy, or your body?If so, please list a few below:
Do you believe your body is capable of conceiving and carrying a healthy baby? Why or why not?
Why do you want to become a parent?
How ready are you to commit to rewiring your thoughts and beliefs around fertility?
Ready
Somewhat Ready
Not Sure
What would success look like for you?
Submit
Should be Empty: