Practical Support Request Form

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This form is for abortion fund case managers from any U.S. region to use to request logistical on-the-ground support facilitated by the DMV Abortion Practical Support Network. Practical support includes transportation, lodging, escorts, childcare, etc. needed by patients receiving abortion care in the DC area.

For further questions, please email dmvpracticalabortioncare@gmail.com.

Case Manager (CM) Information

Lead CM Full Name *

Lead CM Email Address *

Lead CM Phone Number *

Alternate CM Full Name (ie. next CM on duty)

Alternate CM Email Address

Patient Information

Patient First Name and Last Initial *

Patient Phone Number *

Can patient accept texts and/or voicemails?

Ok to text

Ok to leave voicemail

Ok to call

Is the patient a minor?

Yes

Clear selection

Is patient traveling with a companion?

Yes

Clear selection

If yes, how many?

Is the patient traveling with children?

Yes

Clear selection

If yes, how many?

Appointment Information

Most patients traveling to the DMV to receive abortion care are typical coming for 2nd and 3rd tri procedures. These procedures typically take between 2-4 days so please provide all the days the patient will be here for care and need practical support.

At what clinic is the patient receiving care? *

Clinic Address

What are the appointment dates and times? *

Transportation Assistance

How is patient traveling to DC area?

Driving

Train (Amtrak)

Flying (DCA)

Flying (BWI)

Flying (IAD)

Clear selection

Is patient requesting assistance with local transportation?

Yes

Clear selection

If yes, what dates/times and to and from where specifically?

Note: If applicable, please include how far prior to their appointment time they should arrive at the clinic, and the anticipated time window for the procedure to estimate pickup.

Lodging Assistance

Before reaching out on the behalf of a patient about housing please make sure you have had a conversation with the patient to ensure they are comfortable staying in someone's home and that it is ok too if they are not. Make sure they know we have an amazing group of volunteers that are more than happy to welcome them into their homes and support them while they are in the DMV receiving abortion care. We want patients to know this is an option that would not only help alleviate the financial burden of traveling but also be a supportive and caring environment for their stay.

Is patient requesting assistance with lodging/housing? *

Yes

Is the patient comfortable staying in a volunteer's home in a spare bedroom? *

Yes

Maybe

If yes, what nights specifically? When would they plan to arrive and depart?

Is the patient ok staying somewhere with pets?

Yes

Clear selection

Is the patient ok staying somewhere with children?

Yes

Clear selection

Does the patient have known allergies the host should be aware of?

Yes

Clear selection

Additional Information

Is there anything else we should know about the patient and their practical support needs?

Submit

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