AACE Inquiry Form

AACE Inquiry Form

Please complete if you are seeking abortion recovery care.
Date

MonthDayYear
Date
Name
Address
City:
Zip:
County:
Phone number
Email
example@example.com
May we contact you? Select all that apply.*

Yes, you may contact me by phone.Yes, you may contact me by email.Yes, you may contact me by mail.Yes, you may contact me by phone. Please use Caller ID to block
Date of Birth

MonthDayYear
Date
Age:
Have you been here before?

NoYes
If yes, when?
How did you hear about us?
If you were referred to the LPC. Who referred you?
All AACE services are provided FREE of charge to you by The LPC. The AACE program offers individual care and group support programs. We provide care to women and men.
When was the date of your most recent abortion(s)?
type in your due date MM/DD/YYY
If applicable, are you currently pregnant?

YESNO
If YES, when is your due date?
type in your due date MM/DD/YYY
Limitations of Services

The LPC is a non-profit Christian organization. The staff and volunteers have received training in peer counseling and do not, for the most part, have degrees in counseling. The counseling provided is not, therefore, intended as a substitute for professional therapy. We provide ministry and counseling care through the framework of a biblical worldview. We do not require or expect those we serve to hold that worldview. It informs who we are. The LPC does not recommend or refer for abortions or birth control. We will provide peer counseling, education, and information about these topics.

The LPC provides a non-profit medical pregnancy help clinic. Medical services are provided by licensed medical professionals.

These services are provided free to anyone.

I have read and understood the above and hereby authorize the staff of this clinic to render whatever services are necessary for my care.
I hereby authorize and permit the Laurel Pregnancy Center to contact me.
Signature *

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