Urgent Support Form
Hi, thanks for being here; we are glad you found us. Take a breath and know you are not alone. For everyone's privacy and security we have some requirements for those seeking abortion support. Although we are looking forward to get to know you better, we will all be using pseudonyms for the duration of our support and care. These precautions are not intended as barriers to care and genuine relationship, but tools to build a foundation of trust and vulnerability. They are an evolving attempt to protect those that are most vulnerable in the best ways we know how.
This form is HIPPA compliant and encrypted, but that does not mean the account is safe from hackers or others who may work outside of legal restrictions. Please take this into consideration before submitting your responses.
What name would you like us to use when reaching out to you?
Remember: Doesn't have to be, and maybe shouldn't be your real name!
What county and state (or province) are you currently seeking care in?
*
What are your pronouns?
*
How old are you?
*
What was the date of your last menstrual period?
*
If you don't have an exact date, please estimate with as much accuracy as possible
Please let us know what we can help with
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I want an abortion and I need to know all my options.
I need help obtaining a medication abortion.
I am less than 6 weeks from my last menstrual period and I want to know about herbs.
I would like an extraction, but don't know where to start.
My abortion is complete and I would like a consultation for post partum support and healing.
Other
Do you have immediate safety concerns (physically, emotionally or socially) we should be aware of?
Your responses are confidential.
Do you have a someone that can support you in person?
What is your preferred way of contact?
Phone call (Must be through Signal private messenger)
Text (Must be through Signal private messenger)
Email (Must take place through encrypted email. Get a free account through Protonmail. Open with a private browser like Tor, Firefox private, or duckduckgo)
Web meeting (Link will be shared through encrypted email or messenger app. Open with a private browser like Tor, Firefox private, or duckduckgo)
If preferred email, please leave your encrypted email account here:
example@protonmail.com
If preferred phone, after downloading Signal, please leave your phone number here.
Please enter a valid phone number.
If you are outside of the US, after downloading Signal, please share your number here.
Is there anything else you'd like us to know BEFORE setting up your consultation with an abortion doula?
*We are a small team, and getting you connected with an available doula can take anywhere from 1-3 days.
If you have a specific medical question or concern about your abortion you can reach out to the M+A Hotline to talk with licensed medical staff. 1.833.246.2632
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