Christmas Fertility Gift Give Away Assessment

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*

Tubes are Tied
Blocked Tubes
Scarred Tubes
PCOS
Endometriosis
Other

Please Explain "Other"

Do you have a regular period? (ovulation)*

YES
NO
Irregular

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

Yes
No

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*

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 children do you have?*

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

Yes
No
Does not apply

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

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...*

working with Saskia in a private Fertility Program
working with Saskia in a group Get Pregnant Program Fertility Program
attending a Fertility Workshop with Saskia
None of the above, I just want to speak with Saskia

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

Yes I am so ready!
Maybe, depends on price
No, I am not ready now

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

Yes. Absolutely!
No, there is no way I can afford it
Maybe, after my questions are answered

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?*

Please Describe "Other"

Who can we thank for referring you?

Name*

First Last

Email*

Phone*

Address*

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

Enter to Win Saskia's 4-Month Fertility Program