Confidential Abortion Recovery Intake Form
Please complete this confidential form to help us support your healing journey.
SECTION 1: CONSENT
By completing this form, you acknowledge that this program provides spiritual and emotional support and is not a substitute for licensed medical or psychological care. Your responses are confidential.
Do you consent to participate in this intake process?
*
Yes
No
SECTION 2: BACKGROUND
Background Information
Rows
Yes
No
Prefer not to answer
My abortion occurred more than one year ago
I was a teenager at the time
I was more than three months pregnant
I do not know the name of the doctor
I have had more than one abortion
Very few people know about my abortion
SECTION 3: CIRCUMSTANCES
Rows
Yes
No
Prefer not to answer
I felt pressured by others in my decision
The baby’s father wanted the abortion
The baby’s father left the decision to me
I believed abortion was wrong but felt I had no choice
SECTION 4: EMOTIONAL & MENTAL HEALTH
Rows
Never
Rarely
Sometimes
Often
I struggle with guilt or shame
I have unresolved feelings about the abortion
I feel sad or depressed often
I have lost interest in things I once enjoyed
I feel angry or irritable
I fear something bad may happen to me
I experience nightmares or flashbacks
These occur at least monthly
There are details I cannot remember clearly
I avoid reminders of the abortion
SECTION 5: PHYSICAL & BEHAVIORAL
Rows
Never
Rarely
Sometimes
Often
I experienced physical complications
I have difficulty sleeping
I struggle to concentrate
I use alcohol or substances to cope
I engage in relationships I later regret
SECTION 6: CURRENT PERSPECTIVE
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel emotional pain related to the abortion
I believe I made the right decision
I feel at peace about the experience
I would choose abortion again in a similar situation
SECTION 7: OPTIONAL SHARE
If you would like, share anything about your experience that you feel is important for us to understand:
SECTION 8: CONTACT (OPTIONAL)
Name (First Name is enough)
Email
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: