Keys to Hope and Healing
Participant Questionaire
Personal Information
Full Name
*
First Name
Middle Initial
Last Name
Date of birth /Age
Have you had , been part of, or been affected by your own or someone else's abortions?
*
Please Select
Yes
No
Phone Number
*
E-mail
*
example@example.com
Clinical or Abortion Healing Support Group readiness assessment
Have you attended counseling, abortion healing,or other programming to address the impact it has had on you?
*
yes
no
Are you now or have you in the past have thoughts of harming yourself or others?
*
Yes, presently
Yes, in the past but not currently
no
Are you currently experiencing any other symptoms or stressors in life like depression, anxiety, addictions, domestic violence, relationship issues, homelessness, unemployment, recent trauma or loss other than you abortion experiences?
*
yes
no
If yes, please specify any symptoms or stressors.
On a scale of 1-4 with 1= rarely , 2 = sometimes, 3 = often, 4 =Most of the time. How are your activities of daily living impacted by the symptoms or stressors of life mentioned in the question above?
*
1 rarely
2 sometimes
3 often
4 most of the time
Please elaborate if your activities are often impacted.
Are you currently seeing a mental health therapist?
*
yes
no:
If so, does your therapist support your participating in abortion healing?
*
yes
I don't know
no
I am not currently seeing a mental health thaerapist
Are your parents/spouse/partner/friends supportive of your interest in receiving abortion healing?
*
yes
I haven't told them
no
What kind of abortion did you experience
*
medical (at home)
surgical (at clinic)
How long ago was your abortion
*
less than a year
1 -5 years ago
5+ years ago
Permission to contact by (choose any or all that apply)
*
email
text
phone
If you are not EST time zone, please let us know your time zone.
Which type of support are you seeking
Secular
Faith Based
No preference
Submit
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Month
-
Day
Year
Date
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