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Financial Assistance Request Form
Texas Clinics
Patient Name (First and Last)
*
Enter your full name exactly as it appears in the clinic's records.
Clinic Name
*
Please Select
Houston Women's Reproductive Services
Austin Women's Health Center / Brookside Medical
Pegasus Health Justice Center
Planned Parenthood South Texas 2140 Babcock Rd
Planned Parenthood South Texas 920 San Pedro Ave
Planned Parenthood South Texas 235 Richland Hills Dr
Planned Parenthood South Texas 11514 Perrin Beitel Rd
Planned Parenthood South Texas 7022 S. New Braunfels Ave
South Austin Planned Parenthood 201 E. Ben White Blvd
Downtown Austin Planned Parenthood 1823 E 7th St
North Austin Planned Parenthood 9041 Research Blvd
Central Austin Planned Parenthood 2911 Medical Arts St
Northville Health Center - Planned Parenthood
Northwest Health Center - Planned Parenthood
Spring Health Center - Planned Parenthood
Stafford Health Center - Planned Parenthood
Telehealth - Planned Parenthood
Clinic Name calculation for Zendesk
Don't forget to add calculation values in the previous question and a conditional calculation so the value of this field matches the option in Zendesk.
Appointment Date
*
-
Month
-
Day
Year
Date
What is your appointment for ?
*
Ultrasound/Consultation
Birth Control, IUDs
STI Testing & Treatment
Miscarriage Management
Wellness Exams
Gender Affirming Care
Emergency Contraception
Appointment for calculation for Zendesk
Don't forget to add calculation values in the previous question and a conditional calculation so the value of this field matches the option in Zendesk.
What is the total cost of your appointment?
*
Please enter the dollar amount using only numbers
How much money do you need for the cost of your appointment? Lilith Fund may be able to provide $500 per appointment
*
Please enter the dollar amount using only numbers
Are you receiving financial assistance from the clinic or other organizations to help with the cost of your appointment?
No
Yes
Unsure
Lilith Fund only provides funds for legal purposes and is working to comply with recent legal changes. Please indicate your understanding and agreement with this statement.
*
Please Select
Yes
No
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Age
*
Contact clinic staff if the patient is under 18.
Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender Identity
Please Select
Female
Male
Transgender
Non-Binary
Other
Choose the option that best represents your gender identity.
Racial Identity
Black or African American
Hispanic/Latino
White
Asian
American Indian/Alaska Native
Other
Employment Status
Please Select
Unemployed
Employed
Other
Please choose the option that most accurately represents your current employment situation.
Health Insurance
Please Select
No, uninsured
Yes, insured
Other
Please choose the option that accurately represents your health insurance coverage.
What is your primary language?
*
Please Select
English
Spanish
Other Language
Are you a parent?
Please Select
Yes
No
Please choose the option that describes your parental status.
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Next
Would you like someone from our team to contact you for extra help?
Abortion Resources
Pregnancy Resources
Travel Resources
Emotional Support
Something Else
Would you like a member of our team to connect you to local organizations and resources? If so, please select all that apply. Please note: We don't fund these services but will connect you to the organizations that do.
Housing Resources
Employment Resources
Health Insurance Resources
Childcare Resources
Utility/Rent Resources
Clothing Resources
Emotional Support & Resources
Something Else
How did you hear about us?
*
Clinic
Web Search
Social Media
Friends/Family
Online Ads
Former Client
Another Organization
Hear about us calculation for Zendesk
Don't forget to add calculation values in the previous question and a conditional calculation so the value of this field matches the option in Zendesk.
Can we follow up with you via text?
*
Yes
No
Would you like to receive emails from the Lilith Fund?
*
Yes
No
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
If you’d like, please leave a message for Lilith Fund and its supporters who contribute to this funding. Your message might be shared anonymously with supporters of Lilith Fund
Please complete the captcha:
*
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