Get Pregnant Now Fertility Programs

Fertility Consultation Form

Please note: you must fill out this intake form before your 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

TikTok

Youtube

IGTV

Fertility Hub

Virtual Conference

Podcast

TV Interview

Google Search

Magazine

Online Magazine

Referred By Someone

Book- The Naked Truth of Unexplained Infertility

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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