Pre Discovery Call Questionnaire

Full Name *

Phone *

Email *

Date of birth *

Relationship Status *

Occupation *

Referred By? *

How long have you been trying to conceive? *

How has this negatively impacted your life (finances, relationships, work, sleep, etc)? *

What have you tried so far that hasn’t worked? *

How much money would you estimate that you have spent trying to get pregnant? *

What is your age? Your partner’s age? *

What about your fertility journey has been the hardest so far? *

Why is now the right time for you to do this? *

What are your main health concerns beyond getting pregnant? *

Do you believe that you can get pregnant? *

Absolutely

I think so

Not sure

No I don’t

Our individualized approach has resulted in improved fertility for many clients in a matter of a few months; however it requires time, an emotional, and a financial investment. How ready are you to invest in getting & staying pregnant. *

Extremely ready-- let's get started! I have the financial resources to invest in getting & staying pregnant.

I'm ready--I can get access to the financial resources needed

Not sure if I am ready -- limited time, emotional or financial resources

Not ready at all--I don't have access to financial resources or I don't have the time or emotional bandwidth to invest in getting & staying pregnant.

On a scale of 1-10, how committed are you to getting and staying pregnant? 1=Not at All, 10=100% committed *

Is there anything else that you would like me to know about your health, history or goals? *

In which country do you live? *

If USA, in which state do you live? *

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