Jax Set Free Interest Form

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

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Name*

First NameLast Name
Birth Date*

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Email*
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Number*
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Zip Code*
How did you hear about Jax Set Free?*

websitesocial mediafriend / otherreferral from First Coast Women's Servicesevent
Marital Status*

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Many people have multiple abortions. How many abortions have you had or been involved with?*
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.
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Yes, I am interested in learning more about Jax Set Free and abortion healing.