West Fund Abortion Funding Request
Thank you for reaching out to the West Fund. Please fill out this form to the best of your ability and a case manager will get back to you within 48 hours.

We are an all volunteer fund, and wish we could fully fund every request. But we have to stretch our funds, so we can only provide a fraction of your procedure cost.

We deeply respect your privacy and will keep all of your information confidential. However, if you have any concerns about the security of the computer, phone, or tablet you are using to fill out this form (for example if it is a public computer or belongs to someone else who doesn't know about your situation), we recommend that you do not begin the application until you can use a more secure device.

Si quiere llenar esta forma, oprime aquí: https://docs.google.com/forms/d/1C9mCjUX9angPE6oevTRTeCfgqLIu819A0TLMg2g4GlQ/viewform
Sign in to Google to save your progress. Learn more
Are you 18 or older? *
If you are younger than 18, you need parental consent to get an abortion in Texas. We can still help you with funding if you are under 18. If you do not think you can get your parent's consent, please visit janesdueprocess.org or call 1-866-999-5263.
Full Name *
Please enter the name you will use at the clinic.
Preferred Name
Tell us what you want us to call you -- this may be different than the name you use for the clinic.
How We Can Contact You
Preferred Method of Contact: *
(including any other instructions to maintain privacy & safety)
¿En español?
(Please have a Spanish-speaking volunteer contact me.)
Phone Number: *
Please provide a phone number our volunteers can call to talk to you about your case. If you would like to provide more than one number, add the additional number(s) in the field below.
Alternate Phone Number (if applicable):
Email Address: *
Please do not provide your email address if it is not safe to email you.
Let us know what you prefer: *
How is it safe to contact you?
Where do you live? *
We currently only serve people who live in Texas or Southern New Mexico. To find a fund that can serve your location, visit fundabortionnow.org
About Your Situation
How far along are you?
How long have you been pregnant in weeks? Health professionals usually measure a pregnancy in terms of the time that has passed since the first day of your last menstrual period (abbreviated as LMP). If you go to a clinic, they may use an ultrasound machine or a physical exam to establish how far along you are.
Date of Procedure
If you do not have a procedure scheduled yet please write "not scheduled yet." If you need a referral write "I do not know where to get one"
Name of Clinic:
Where did you make an appointment?
Cost of Procedure:
How much did the clinic tell you the procedure would cost, in total?
Health Insurance
If you do have health insurance or Medicaid, you can still get help from us. We know that even if your plan covers abortion care, your deductible may be more than the out-of-pocket cost of your procedure. We also know that in Texas, Medicaid never pays for abortion care. If you do have health insurance that is not Medicaid, we will ask you if you have contacted your plan about whether or not they cover abortion. We understand that even if they do cover abortion you may not have enough money to pay your portion.
Let us know if there is anything else we should know about your situation.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy