The Fertility Nurse: Personal Coaching - Phone Call Request Form

Personal Coaching

Request Free, No-Obligation Phone Call

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 request a free, no-obligation phone call to discuss setting up a coaching relationship.

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 on your call.

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?

Call Information

In the space below, prioritize the days and times that you have available for a coaching call appointment.

Based upon what you prioritize here, we will email to you three appointment options that are available in our schedule.

Specify days of the week and the periods (morning, afternoon, or evening) that work best. Include blackout dates or other notes regarding your availability that would help us select a convenient appointment time for you.

Reason(s) you are requesting coaching:

What are your goals for a coaching relationship? Or what do you hope to know or feel or experience because of this relationship that you do not know or feel or experience now?

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:

By submitting this request you are fully agreeing to this disclaimer.

Personal Coaching is billed at $125 per hour. A 15% discount is given when 5 or more hours are purchased. A 25% discount is given when 10 or more hours are purchased.

If after the second coaching call you are not satisfied for any reason, cancel the service prior to the start of the third coaching call and we will provide a full refund. The first two coaching calls are on us.

You can terminate the coaching schedule at any time after the third coaching call and we will refund all unused time.

	Schedule a call. Submit an online request for a phone call to discuss Personal Coaching services.
	Talk with a coach to set a coaching schedule. You will receive a no obligation, free phone call to discuss your situation. On this phone call, a coaching schedule will be personalized for your needs.
	Receive an invoice. If you decide to move forward with Personal Coaching, you will receive an email invoice for the total time represented in your personalized coaching schedule.
	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.
	Proceed with coaching schedule. Make calls to your fertility nurse at the scheduled times and receive one-on-one personal coaching tailored to your ongoing infertility situation.


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

info@thefertilitynurse.com

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