Self-Guided Abortion 1-on-1 Intake
This form helps me to better understand your needs and how best to support you. All information is confidential and used only for the purpose of your sessions.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What kind of support are you seeking? (check all that apply)
Emotional processing
spiritual integration
guidance through regret and/or grief
Grief and closure
Other
If other, expand here
What have you been experiencing since your abortion? How long ago was your abortion, and what things do you hope to address in these sessions?
In order to begin, I offer a free 30-60 minute session to better assess your needs and make sure we are a good fit. Is it ok if I email you to schedule?
yes
no
Submit
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