Request for Material Support

Material Needs Request Form

The LPC’s mission is to demonstrate Christ’s love to women and men facing unplanned pregnancy, or previous abortions by offering spiritual, physical and emotional care. We offer material assistance to these clients throughout their first year, and beyond. We also recognize that life is messy and sometimes you find yourself in a place where you just need help. If you are a parent who already has a baby and/or small child, and you are in need of material assistance, we are here for you too. We are able to offer you some diapers and wipes to assist with your urgent need. We can also get you connected to some other resources who can assist with other material needs, such as clothing items, formula, cribs, strollers, etc. Please fill out this form and we will get back to you.
Type a question
Date

MonthDayYear
Date
Name *
Address *
City: *
Zip: *
County: *
Phone number*
Email*
example@example.com
Can we contact you for follow-up?*

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

MonthDayYear
Age:
Have you been here before?*

NoYes
If yes, when?
How did you hear about us?
If applicable, are you currently pregnant?

YESNO
If YES, when is your due date?
type in your due date MM/DD/YYY
If NO, current age of your child(ren)
Diapers
* please note that we do not always have specific sizes in stock.
Clothing Size
Other needs
*due to liability, the LPC does NOT carry baby equipment.
Limitations of Services

The Laurel Pregnancy Center is a non-profit Christian organization. The staff and volunteers have received informal 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. The LPC affirms a biblical worldview. It is the framework for our care and education. We do not expect or require anyone we serve to share a biblical worldview.

The LPC services include a non-profit medical pregnancy help clinic. Our medical services are provided by licensed medical professionals. They provide general pregnancy health education and information. They are not a substitute for dedicated prenatal care.

All pregnancy help 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.
The LPC takes confidenciality very seriously. We do not relase personal or case information to third parties unless: 1) there is evidence that the client is a harm to self or others, or 2) in cases of abuse defined by the state.
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Material Needs Request Form