Post-Abortion Intake Form
We're glad you took the step to ask for help. We will do all that we can to walk with you through this time. Please do your best to fill out the following intake form. These questions are designed as an initial step to help us assess your needs. We understand the sensitive nature of these issues and that it may be difficult for you to reveal this information. Your confidentiality is highly respected.
Today's Date *
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General Information
Name *
Your answer
Address *
Your answer
County *
Your answer
City *
Your answer
State and Zip *
Your answer
Which location do you prefer? *
Phone (please designate home or cell) *
Your answer
Cell Phone Text
Email address *
Your answer
Age
Your answer
Birthday
Your answer
Race
Your answer
Referred by
Your answer
Marital Status
If married, what is your spouse's name?
Your answer
Have you recently lost someone close to you by death? If so, who? When?
Your answer
Religion
Your answer
Church
Your answer
Occupation
Your answer
School
Your answer
Pregnancy Related
How many children have you carried to term (if applicable)?
Your answer
What are the names of your children (if applicable)?
Your answer
How many miscarriages have you had (if applicable)?
Your answer
Abortion Related
How many abortions have you had?
Your answer
1st abortion: How old were you?
Your answer
Martial Status at that time
Your answer
Type
Check one
Physical complications incurred:
Your answer
Main reason for aborting:
Your answer
Did you feel pressured into having the abortion?
Your answer
Would you have carried your baby if the father of the baby was supportive?
Your answer
2nd abortion: How old were you?
Your answer
Martial Status at that time
Your answer
Type
Check one
Physical complications incurred:
Your answer
Main reason for aborting:
Your answer
Did you feel pressured into having the abortion?
Your answer
Would you have carried your baby if the father of the baby was supportive?
Your answer
3rd abortion: How old were you?
Your answer
Martial Status at that time
Your answer
Type
Check one
Physical complications incurred:
Your answer
Main reason for aborting:
Your answer
Did you feel pressured into having the abortion?
Your answer
Would you have carried your baby if the father of the baby was supportive?
Your answer
Have you suffered any other pregnancy losses (additional abortions, still-born)? If so how many?
Your answer
Have you ever discussed the impact of the above abortion(s) with anyone (Yes or No) Who?
Your answer
When and how did you come to believe that you needed help in dealing with the above abortions?
Your answer
What have you experienced emotionally since the abortion(s)?
Your answer
Are you currently on any anti-depressant or anti-anxiety medication?
Your answer
Thank you for giving us this initial information. I will go over this form with you and may ask some additional questions as well. We hope that you will have the freedom to express any emotions that may be surfacing as you talk about your abortion experience.

Thank you,

Jama Edlund
Her Choice to Heal Coordinator
If Not For Grace Ministries

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