Get Pregnant Now Fertility Programs

Fertility Consultation Form

Please note: you must fill out this form before a consultation is scheduled.

*Note: If both of your tubes are tied please do not fill out this application,
Saskia will not be able to help you. Please see your Doctor.

"*" indicates required fields

How long have you struggled to become pregnant?*

Up to 1 year

2 Years

3 or more years

Have you ever tried IVF or IUI?*

Yes

No

Why have you not tried IVF or IUI?

How many times have you tried IVF or IUI

1 time

2 times

3 times

4 times or more

Please explain your experience with IVF or IUI

Does the Doctor Tell You:*

You should be able to get pregnant

You cannot get pregnant

You have unexplained infertility

I have not seen a doctor yet!

Why have you not seen a doctor yet?

Do you have any of the following*

Unexplained Infertlity

Tubes are Tied

Blocked Tubes

Scarred Tubes

High FSH

Low AMH

PCOS

Poor Egg Quality

Endometriosis

Secondary Infertility

Other

*Click all that apply

Do you have / or experienced

Trauma Block[s]

Mindset Block[s]

Emotional Block[s]

Mistrust Block [s]

Other Block [s]

Please Explain "Other"

Has the doctor told you that you cannot conceive naturally?*

Yes

No

Do you have a regular period? (ovulation)*

YES

NO

Irregular

Explain what the doctor has told you*

Have you experienced any of the following :*

Emotional Trauma

Miscarriage

Rape

Loss of a Child

Abortion

Adoption

Childhood Trauma

None of the Above

Check all that apply

Have you been diagnosed with a mental health issue?*

Yes

No

Please explain your mental health

What is Your Age Group*

20-25

26-30

31-35

36-40

41-44

44-48

48 and over

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

Yes

No

No, I am happy to start a family as a single mom

Do you have children of your own?*

Yes

No

How many "live" births have you had?*

Does your husband/or significant other want a baby with you?*

Yes

No

Does not apply

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!

How many children do you want to have?*

Is your husband/partner sperm fertile?*

Yes

No

Low Sperm Count

Not Sure

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

Yes

No

Describe your Fertility Journey

What is your highest priority right now*

Getting Help to Get Pregnant Now

New Home/ or Remodel

Growing my career

Paying off debt

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?*

Why is now the right time to get Saskia's help?*

Which of these are you interested in...*

Private Fertility Coaching

Get Pregnant Now Foundation Program

High-End Private Fertility Coaching with Saskia ONLY

None of the above, I just have questions about my fertility challenges

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

Once you have your questions answered are you ready to start the Get Pregnant Program Now this month?*

Yes I am so ready!

Maybe, depends on price

Maybe in 3 months or more

No, I am not ready now

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

Yes. Absolutely!

Yes, but in Private Coaching Only

No, there is no way I can afford it

Maybe, after my questions are answered

Maybe, but I have a lot of doubts

What could stop you from joining the Get Pregnant Now Fertility Program?*

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 +

How did you hear about my fertility program?*

Facebook

Instagram

LinkedIn

Youtube

IGTV

Fertility Hub

Virtual Conference

Podcast

TV Interview

Google Search

Magazine

Online Magazine

Referred By Someone

Other

Please Describe "Other"

Who can we thank for referring you?

Name*

First Last

Email*

Cell Phone*

or Best Contact Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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