Shine Fertility Friends New Member Match Survey
Thank you for your interest in Fertility Friends! Your survey responses will be input into our greater database where you will be matched with a mentor with similar attributes, and your survey responses will be confirmed with a “Thank you” email.

* If you are looking to speak to a mentor just once (versus establishing a relationship), please skip this survey and contact us at info@shinefertility.org. We will be sure to put you in touch with someone who can help.
First Name *
Your answer
Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State, Zip Code *
Your answer
Phone number (including area code) *
Your answer
Email Address *
Your answer
At what age did you start trying to get pregnant?
Your answer
What is your current age?
Your answer
Were you diagnosed with a specific type of infertility? If yes, what? (ex. PCOS)
Your answer
What doctor(s) and clinic(s) are you with?
Your answer
How many IUI procedures?
Your answer
How many IVF procedures?
Your answer
Any other procedures you had to undergo?
Your answer
Who is your support system?
Your answer
What other support are you using to supplement your treatments (check all that apply)?
Do you have family or friends that had experienced similar issues?
Your answer
What types of communication with your mentor are you comfortable with? (check all that apply)
How do you plan to pay for your fertility treatments?
Please include any other information that will help us best place you with a mentor (ex: what do you hope to gain from this relationship, anything other specific wants/needs, example- I'd like weekly check ins, if possible matched with someone from same clinic/doctor, etc)
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Shine: A Light On Fertility. Report Abuse - Terms of Service