Background American Society of Reproductive Medicine and American Society of Clinical Oncology emphasize the importance oncofertility counseling. Survivors often report inadequate attention to this crucial aspect of care. Balancing timely treatment initiation with oncofertility counseling presents challenges including cost, age at diagnosis, information overload, and time constraints. Procedures We performed chart abstraction of 265 pediatric patients diagnosed at University of Rochester Medical Center (January 1 st 2015 - May 31 st 2022). Hematologic malignancies made up 37.65% of the population. Median age was 7 with male predominance (56.2%). The majority of patients were Caucasian (80.7%). Results Only 12.5 % of the population had an oncofertility visit with reproductive endocrinology or urology and 42.4% had documented counseling with their oncology team. Sexual health was discussed in 2.6% of patients and 12.1% of patients had documented Tanner staging. Hematologic malignancy patients had a lower time to therapy (4.2 days) compared to extracranial solid tumors (14.8 days) and CNS tumors (97.8 days) when outliers were removed. Longer time to therapy trended towards significance for oncofertility visits and there was no statistical difference in oncofertility vists or primary team counseling rates based on disease severity. Conclusions The time before chemotherapy initiation is a unique barrier to oncofertility counseling for pediatric patients with malignancy. While most patients will have retained fertility on current protocols, patients with high risk of relapse will receive therapy more likely to threaten fertility. The results of this study indicate targeted intervention prior to relapse for this population may be a more feasible approach.