Abortion Aftercare Support Kit: Request Form

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 clients with support kits regardless of race, ethnicity, gender, gender expression, sex, sexual orientation, sexuality, disability, illness, class, age, language, immigration/citizenship status, criminal history, religion, spirituality, political affiliation, occupation, or any other identifiers. Each support kit contains:

- 4 maxi pads
- 3 regular pads
- 4 liners
- 1 heating pad
- 1 bottle of water
- 3 Emergen-C packets
- 1 small journal
- 1 pen or pencil
- 1 pocket tissue pack
- 1 Support Kit Manual (with tips, guidelines for using each item, and resources)

Please fill out this form as honestly as possible. SPIRAL has limited resources, but we will do our best to accommodate each and every one of our clients.

*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.

**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.

Your answer

Client's Email Address (optional)

Your answer

Client's Phone Number (optional)

Your answer

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")

In person only (please provide details in "Other")

Other:

Required

By what date do you need a support kit? *

YYYY

How would you like to receive your support kit? *

PICK-UP: Pick it up from a representative of the SPIRAL Collective

DROP-OFF: Arrange for a representative of the SPIRAL Collective to drop it off wherever is most comfortable/convenient for you

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

Please provide a specific address.

Your answer

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.

Your answer

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:

Prefer reusable pad/liner (we will try to accommodate if we can)

Yes

Any allergies? *

Your answer

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.

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