Name
Email
Phone Number
Age
In the next twelve months, what changes would you like to make to your fertility health or education?
What have you struggled with the most in dealing with fertility struggles?
So far in your journey, what have you tried to get pregnant?
When it comes to making your health a priority, what level of investment feels aligned for you? $500-$2,000
$2,000-$4,000
$4,000-$6,000
$6,000-$10,000
$10,000+
Is there anyone else (spouse, partner, parent) involved in your healthcare decision-making process? If so, will they be attending the call? Yes
No
How soon are you looking to start working with us? Immediately
Within the next three months
Within the next month
I'm just exploring options for now
What is the primary reason you are seeking concierge care over traditional care? More personalized attention
Holistic care and support
Looking for a trusted partner in my health journey
Access to longer appointments
Convenience and flexibility
If we could wave a magic wand and help you feel your absolute best this year- physically, mentally, and emotionally- what would that look like for you?
How committed are you to making lifestyle changes to reach your health goals? Fully committed, willing to do whatever it takes
Looking for guidance, but not sure if I can fully commit yet
Somewhat committed, but not sure if I can fully commit yet
What is your preferred level of communication and access to your health coach? Frequent check-ins and direct messaging
Monthly check-ins
Weekly updates and calls
I prefer less frequent communication, only when needed
Do you know we operate as a concierge practice (no insurance billing, high touch care model)? Yes
No, I'd like to learn more
What are you looking for in a care team?
How do you prefer to be supported in your care? In-depth visits with personalized guidance
A structured program with accountability
Regular communication between appointments
Evidence-based supplements
Nutrition, lifestyle, and educational resources
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