New York Abortion Doulas Intake Form
Abortion doulas are here to help emotionally and physically during, and/or after your abortion. We are here to provide information and help navigate the medical system to make your experience be more comfortable. We are independent and our role is to support YOU. 

Here is a list of what we are currently able to provide. All of our services are free, and offered by our collective of volunteers.

Please fill out this form to the best of your ability. Your personal information will never be shared outside of NYAD, unless with your explicit consent (e.g. reaching out to funds on your behalf).

We will do our best to respond to you within 48-72 hours. We cannot guarantee support for all requests.
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Preferred Name and pronouns
(first name only is fine)
 *
What Is Signal?
Signal is a more secure way to communicate than regular phone/email/text. It is an end-to-end encrypted messaging app that allows one to set "disappearing messages" to keep conversations more private.

You can download Signal on mobile (Android or iPhone) and/or desktop here.
Phone number or Signal username *
What is the best way to contact you? *
Required
If you know, how many weeks along in pregnancy are you? (You can calculate from your first date of your last menstrual period if you're not sure)
How would you like a doula to support you?
Would you like to be matched with a doula who shares a specific identity with you? (We cannot guarantee this, but we will do our best. Choose all that apply.)
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