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Fertility Consultation Application

This application helps us to prepare for your individualized Consultation. 

You have our promise that everything you share with us is completely confidential.

Click the button below to start.

Start

Question 1 of 14

How would you like to be contacted for your FPI Consultation?

A

Video Zoom

B

Audio Zoom

C

Phone Call

Question 2 of 14

Your Best Phone Number

Question 3 of 14

Age

Question 4 of 14

Who referred you to The Fertility & Pregnancy Institute?

Question 5 of 14

When would you like to be pregnant?

Question 6 of 14

What do you think is (or will be) your biggest obstacle to getting pregnant?

Question 7 of 14

Please briefly describe your fertility and pregnancy history. Include whether you have already started trying, anything you have tried, and any previous losses.

Question 8 of 14

How would being pregnant and having a family change your life for the better?

Question 9 of 14

How is not being pregnant or having the family you dream of affecting your life?

Question 10 of 14

Do you have a partner who needs to be present in order for you to make decisions about your fertility?

Question 11 of 14

Would you like for your partner to participate in our call?  If you answer "Yes" please be sure that your partner is available for the last 20 minutes of our call.

Question 12 of 14

Do you have the time, space, energy, money, & other resources to dedicate to your fertility right now?

Question 13 of 14

A member of the Fertility & Pregnancy Institute (FPI) Team will call you at the time you chose. Please commit to your appointment by typing the following sentence in the box below. "Yes, I promise I will be there for my Fertility Strategy Consultation when the Fertility & Pregnancy Institute team member calls.”

Question 14 of 14

Finally, on a scale of 1 to 10, how committed and determined are you right now to having the baby and the family of your dreams?

A

1

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10

Confirm and Submit