Jax Set Free Interest Form

Yes, I am interested in learning more about Jax Set Free and abortion healing.

Your privacy is important to us. This form is secure and confidential.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Number*
City*
State*
Zip Code*
How did you hear about Jax Set Free?*

websitesocial mediafriend / otherreferral from First Coast Women's Servicesreferral from Hadassah's Hopeeventreferral from the Church of Eleven22
Marital Status*

SingleMarriedDivorcedSeparatedOther
Many people have multiple abortions. How many abortions have you had or been involved with?*
My abortion(s) occurred...*

within the past 6 months1 to 5 years ago5 to 10 years ago10 to 20 years ago20+ years ago
Please select all of the following symptoms that you have experienced since your abortion(s). These could have occurred immediately or in the months/years after your experience(s).*

depressionanxietyanger / rageinsomnia / sleep disturbanceschange in relationshipsemotional numbnessalcohol and/or drug abusesuicidal ideationseating disordersheadachespanic attackssecretiveself harmlonelinessregretrelief
Religious/Spiritual Affiliation or Beliefs*

Christian (Protestant, Catholic, Orthodox)JudaismIslamNone (Atheist, Agnostic)Something else (Mormon, Buddhism, Hinduism, etc.)
If there is anything you would like to share about your story, please share in the space below. This field is not required.
By signing this form, I give Jax Set Free, Inc. permission to contact me by any of the methods (email or phone) that I have provided.
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Yes, I am interested in learning more about Jax Set Free and abortion healing.