Abortion Aftercare Support Kit: Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

***COVID-19 Disclaimer: Abortion Aftercare Support Kits can be obtained via contact-less delivery or pick up.

Please fill out this form if you are in need of an Abortion Aftercare Support Kit (AASK), provided by The SPIRAL Collective (Supporting People in Reproduction, Abortion, & Loss). These kits are designed to aid you in your at-home recovery process. They are intended for anyone recovering from ANY type of abortion, or miscarriage. SPIRAL provides our aftercare support kits at no cost to the client. Thank you to all our supporters who make this possible + sustainable.

** supplies in kits may vary
- 5 different sized maxi pads
- 1 reusable pad
- 3 tea bags
- 1 heating pad
- 1 bottle of water
- 3 Emergen-C packets
- 1 small journal
- 1 pen or pencil
- 1 pocket tissue pack
- 2 nut-free snacks
- acupressure resources
- 1 Support Kit Manual (with tips, guidelines for using each item, and resources)

Please fill out this form to your comfort. The aftercare bags varry and we will do our best to accommodate our clients needs.

*A note on confidentiality: The SPIRAL Collective takes client confidentiality very seriously. Your personal information, including any information revealed through any response that you submit through this form, will not be accessible to any person or entity outside of the SPIRAL Collective. We will keep your information private and secure.
** SPIRAL Collective is committed to providing non-judgmental, consent based support to all clients who seek our services.
**Please fill out this form using the CLIENT's information only. We cannot provide these services through any third party.

Client's Name (optional)

Feel free to give a pseudonym, initials, or no name at all. We do not require your real or full name.

Client's Email Address (optional)

Client's Phone Number (optional)

How do you prefer to be contacted? *

If email, phone call, or text, please provide relevant contact info in the questions above.

Phone call

Text

Facebook messenger (please provide Facebook name in "Other")

Signal or Whatsapp ( please provide which in "other" below)

Other:

Required

By what date do you need a support kit? *

YYYY

How would you like to receive your support kit? ( covid-19 protocols no contact best practices) *

PICK-UP: Pick it up from a representative of the SPIRAL Collective (contactless during COVID-19)

DROP-OFF: Arrange for a representative of the SPIRAL Collective to drop it off wherever is most comfortable/convenient for you (contactless during COVID-19)

If you selected "DROP-OFF," where would you like us to deliver your support kit?

Please provide a specific address.

How would you like us to identify ourselves when contacting you, and/or dropping off your support kit?

E.g., a friend, a package delivery, anonymous, etc.

May we contact you after you receive a support kit? *

If you select "Yes," we will contact you (through whichever method you have indicated above) 10 days after you receive your support kit, in order to check in and follow up with resources and support.

Yes

Other:

Any allergies? *

Thank You - You're Almost Done!

Please click "Submit," and then proceed to Page 2 of the form, through the link provided, in order for us to process your request.

Thank you - you're almost done!

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms