TBAF 2022 Intake Form
TBAF runs an intake voicemail line at 727.314.3956. You can complete our intake by calling that number and leaving a message or by filling out the form below.

Below is a new form from TBAF to complete your intake online, then one of our intake volunteers will follow-up with you within 24-48 hours after you click "submit."

Please note:
1. We typically cannot fulfill same day or next day requests for assistance. If you do not have an appointment scheduled yet, please visit TBAFUND.COM for our updated list of supported clinics, and schedule an appointment, then call our intake line or fill out this form.

2. We are not counselors, but work with some amazing organizations who we would suggest you reach out to, if you're needing additional assistance. These resources are listed at TBAFUND.COM/RESOURCES and include:

• Miscarriage & Abortion Hotline: support to self-manage your miscarriage or abortion @ 833-246-2632 or www.mahotline.org
• All-Options Talkline: peer-based counseling and support @ 888-493-0092 or www.all-options.org
• Reprocare Healthline: peer-based, trauma-informed emotional support @ www.abortionhotline.org
Sign in to Google to save your progress. Learn more
What is your first name? *
What is the initial of your last name? *
(Please do not list your full last name.)
Are you filling out this form for yourself or someone else? *
Are you a minor? *
(We do not need to know your age, but TBAF Case Managers may have additional referrals/follow-up for those who are under 18 years old.)
What is the best number to contact you back at? *
(If you do NOT have a phone number, please list the best way to reach you, like email, etc.)
Is it okay for our Case Managers to follow-up with you via text? *
(Please check all that apply.)
Do you have an appointment scheduled? *
If you have NOT made an appointment yet, please visit TBAFUND.COM for an up-to-date list of our supported clinics. Our website contains links to each clinic's website and contact information. Once you schedule your appointment, please come back to this form or call our intake line at 727.314.3956 to complete our intake process.


All Women’s Health Center of North Tampa @ 14498 University Cove Pl., Tampa FL 33613
Planned Parenthood North Tampa @ 236 E. Bearss Ave., Tampa FL 33613

Bread & Roses @ 1560 S Highland Ave, Clearwater FL 33612

St. Petersburg Women’s Health Center @ 3401 66th St N., St. Petersburg FL 33710

***OUT OF STATE CLINICS (Supported for Florida Residents):
DuPont Clinic (DC)
Washington Surgi-Clinic (DC)
Boulder Clinic (CO)
Hope Clinic for Women (IL)
Planned Parenthood (PPSLR) Fairview Heights (IL)
Park Med (NY)
A Woman’s Choice – (Charlotte NC)
A Woman’s Choice – (Raleigh NC)
+ Others added as of July 1, 2022
Where is your appointment scheduled? *
(Please verify the clinic based on the address listed above, as many Tampa Bay clinics have very similar names!)
What is the date of your appointment? *
Is the above date your first appointment or second appointment? *
(Florida legislators recently implemented an unnecessary law that requires abortion-seekers to have a 24-hour waiting period between their first appointment at their chosen clinic, and their second appointment to start their procedure.)
What time is your appointment? *
What is your Estimated Gestation/how many weeks along is your pregnancy? *
If you're unsure, you can use the calculator @ https://abortionpillinfo.org (see the "Pregnancy Calculator" on the right side of that webpage) OR https://bit.ly/AidAccessPregnancyCalculator .
If you're unsure of your estimated gestation, you can use the calculator @ https://abortionpillinfo.org (see the "Pregnancy Calculator" on the right side of that webpage) OR https://bit.ly/AidAccessPregnancyCalculator
Are you scheduled for the pill or the procedure? *
(The type of appointment you're scheduled for)
Do you need assistance trying to find transportation or childcare during your appointment? *
(Please check all that apply)
Are you in need of financial assistance towards your appointment? *
What is the total price quote that the clinic gave you for your appointment? *
(How much did the clinic tell you that you will owe at your appointment? If the clinic gave you a discount or screened you for funding, please only list the amount you have due after the discounts/other funding assistance.)
Did the clinic screen you for funding assistance through their national funding program? *
(The clinic may have asked you things like income or household member questions, as part of the screening. The clinic may have also referred to this funding as "NAF" or "Justice Funds.")
Do you have any amount towards your appointment already? If so, how much?
(We always ask clients to assess how much you can put towards their appointment, so we can fund as many callers as possible.)
How much of your appointment cost are you looking for assistance with? *
(Please list here the amount of financial assistance you are looking for.)
Did the clinic refer you to any other abortion funds or are you already working with another abortion fund?
(Most people are not, but we only ask this so that we can touch base with those funds and try to provide continuity of care for you.)
Other Pertinent Notes, Concerns, or Questions for our intake volunteers, before they call you back?
Thank you for filling our our intake form! TBAF's intake volunteers will follow-up with you within 24 hours about how much assistance TBAF is able to provide and/or additional resources.

If you have questions about resources (including other resources for abortion, or local resources, including: domestic violence shelters, homeless shelters, food assistance, etc) please visit TBAFUND.COM/RESOURCES

Note: TBAF does NOT store or retain any caller's personal information (ie: full name, address, etc).

Click SUBMIT to finalize intake! THANK YOU!
Clear form
Never submit passwords through Google Forms.
This form was created inside of TBA Fund Inc.. Report Abuse