Fertility Assessment – Get Pregnant Now

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*

*Click all that apply

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

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!

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?*

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

Fertility Consultation