Reproductive Loss Inquiry Form

Reproductive Loss Inquiry Form

Please complete if you are seeking care for reproductive loss.
Date

MonthDayYear
Date
Name
Address
City:
State
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 blockYes, you may contact me by SMS texting
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?
The LPC provides all support and care services FREE of charge. The LPC provides individual peer counseling for various types of reproductive loss.
If applicable, are you currently pregnant?

YESNO
If YES, when is your due date?
type in your due date MM/DD/YYY
Care Coach ethnic preference:

CaucasianPerson of Color (POC)no preference
Approach preference:

Christian faith basednon-faith basedno preferenceOther
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. Therefore, the counseling provided is not 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 to a Christian worldview.

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.
The LPC takes confidentiality very seriously. We do not release 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 as defined by the state.
I hereby authorize and permit the Laurel Pregnancy Center to contact me.
Signature *

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