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Practical Support Request Form
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 or lodging assistance for patients traveling to the DC area to receive abortion care.
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* Indicates required question
Lead CM Full Name
*
Your answer
Case Manager (CM) Information
Lead CM Email Address
*
Your answer
Lead CM Phone Number
*
Your answer
Alternate CM Full Name (ie. next CM on duty)
Your answer
Alternate CM Email Address
Your answer
Patient Information
Patient First Name and Last Initial
*
Your answer
Patient phone number
Your answer
Can patient accept texts and/or voicemails?
Ok to text
Ok to leave voicemail
Ok to call
Is the patient a minor?
Yes
No
Clear selection
Is patient traveling with a companion?
Yes
No
Clear selection
If yes, how many?
Your answer
Is the patient traveling with children?
Yes
No
Clear selection
If yes, how many?
Your answer
How is patient traveling to DC area?
Driving
Train (Amtrak)
Flying (DCA)
Flying (BWI)
Flying (IAD)
Clear selection
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?
*
Your answer
What are the appointment dates and times?
*
Your answer
Transportation Assistance
Is patient requesting assistance with local transportation?
Yes
No
Clear selection
If yes, what dates/times and to and from where specifically?
Your answer
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
No
Is the patient comfortable staying in a volunteer's home in a spare bedroom?
*
Yes
No
Maybe
If yes, what nights specifically?
Your answer
Is the patient ok staying somewhere with pets?
Yes
No
Clear selection
Is the patient ok staying somewhere with children?
Yes
No
Clear selection
Does the patient have known allergies the host should be aware of?
Yes
No
Clear selection
COVID-19
In an effort to keep both patients and volunteers safe, please let us know if you know the following information.
Is the patient fully vaccinated?
*
Yes
No
Unknown
Other:
Is the patient willing to wear a mask inside with volunteer? (driving/housing requests)
*
Yes
No
Unknown
Other:
Additional Information
Is there anything else we should know about the patient and their practical support needs?
Your answer
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