The Fertility Nurse: Coaching Groups

Personal Coaching

One-Time Coaching

Coaching Groups

	Men's Groups
	Women's Groups
	Newly Diagnosed Infertility Patients
	Patients undergoing ART procedures (IVF, ZIFT, FET)
	Patients Using Donor Eggs
	Patients Using Donor Sperm
	Patients Using Donor Embryo
	Patients Using a Gestational Carrier
	Patients Undergoing Ovulation Induction / Intrauterine Insemination
	Join a Coaching Group

Workshop coaching

Exclusive Nurse

Consulting and Research

“We can try to avoid making choices by doing nothing, but even that is a decision.”

- Gary Collins

Complete this form to join a Coaching Group.

The fields marked with an asterisks (*) are required. However, we recommend that you take the time to complete the whole form. The more complete the information you provide here, the better we can serve you in your group.

Coaching Group

*Select the coaching group you want to join:

*Will you be joining this group as an individual or as a couple?

Individual

Couple

Information About You

*First name:

*Last name:

Date of birth:

(mm/dd/yyyy)

Male

Female

Information About Your Partner

First name:

Last name:

Date of birth:

(mm/dd/yyyy)

Male

Female

Your Address

Address Line 1:
Address Line 2:
City:
State:	(SS)
Zip code:	(XXXXX-XXXX)

Contact Information

Home Phone:
Daytime Phone:
Alternative Phone:
*Email:
*Enter email again to validate:
Best way to contact:

How Did You Hear About Us?

Friend

Physician or Fertility Specialist

Name of Physician:
Name of Clinic:

Where?

Internet

Where?

Other

Where?

Treatment Information

How long have you been attempting pregnancy?

Years

Months

Have you seen a fertility specialist?

Yes

Name of physician:

Name of clinic:

Diagnosis given:
Tests performed:
Treatments received:
Medications taken:

Group Information

Have you been a part of a support group or coaching group before?

Yes

What are your expectations for this group?

Do you have specific needs or concerns that you are looking to have addressed in this coaching group? If so, please explain.

By submitting this request you are fully agreeing to this disclaimer and to the costs and terms associated with your selected Coaching Group.

The cost to join a Coaching Group varies depending upon the group and whether or not you are joining the group as an individual or a couple.

Women’s Group:	$490/individual
Men’s Group:	$375/individual
All other groups:	$375/individual $490/couple

If after your second group meeting you are not satisfied for any reason, cancel your participation prior to the start of the third group meeting and we will provide a full refund. The first two group meetings are on us.

	Submit a request. Submit an online request to join this group.
	Receive an invoice. After submitting a request, if the group is not yet filled, you will receive an email invoice for the cost of the group.
	Make payment. Click on the Payment Button in the email invoice to connect to a secure payment page. Make payment via Visa, MasterCard, American Express, Discover, eCheck, or a PayPal balance payment.
	Receive conference call phone number and pass code. After receipt of your payment, you will receive a coaching group conference phone number and pass code via email.
	Call into your group at designated times. Dial the coaching group conference phone number just prior to the start of you scheduled group meetings. When prompted, enter the pass code. You will then be connected to your group and coach.


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For more information, contact the fertility nurse at (888) 245-8299 or

info@thefertilitynurse.com

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