Louisiana Abortion Fund Intake Form

LAAF offers support to folks traveling for legal abortion care from LA, FL, AL, TX, MS, AR, and GA. We provide funding for abortion procedures and are here for you as you navigate the process of accessing abortion care. We do not provide legal or medical advice—please return to the Get Help section of our website for other resources.

Please complete this application as fully as feels comfortable for you. The information in this application is private and confidential, and most of this information will allow us to better meet your needs. Information you share about your pronouns, race, ethnicity, age, and insurance status will NOT impact the funding you receive. These questions help us to learn more about the communities we work within.

All fields marked with * are required and must be filled.

First Name

Last initial

Cell phone number

Is it safe for us to leave a voicemail identifying ourselves as "the fund from Louisiana" if we do not reach you by phone?

What is your preferred language?

Preferred language, if "Other" above

Have you already had an ultrasound?

YesNo

What is your best guess of how far along you are in pregnancy, as of today (separating weeks and days into separate fields, so for eight weeks and five days, you'd write 8 under Weeks and 5 under Days)?

Weeks

Days (0-6)

If unsure, when was the first day of your last regular period to the best of your knowledge?

What state are you traveling from?

LAAF is not able to offer support to folks traveling from outside of our region at this time. However, we can call you to discuss other potential resources for support.

LAAF is not able to offer support to folks traveling from outside of our region at this time. However, we can call you to discuss other potential resources for support. It may also be helpful to know that you can: Speak with your clinic about what financial assistance might be available to you. They are experts in connecting you to the resources available in the region you’re traveling to. Find another fund offering support either where you’re from or where you’re going.

The National Network of Abortion Funds: abortionfunds.org
Funds that can support with your travel: ineedana.com
Call the National Abortion Federation support hotline: 1-800-772-9100
Call or visit Reprocare: 1.833.226.7821

State outside of LAAF's region

What city are you traveling from?

Have you already scheduled an appointment with an abortion provider in a state where it is legal to do so?

YesNo

Date of your upcoming appointment

Clinic name

Clinic name (if not listed above)

Clinic address

What is the total cost of your appointment(s) before support?

Please enter a number

What amount are you planning to put towards the cost of your appointment(s)?

Please enter a number

Have you talked to the clinic about a discount or any additional sources of funding to help with your appointment(s)?

YesNo

How much of the cost is being discounted/covered?

Please enter a number

Do you know if this reduction in cost comes from a clinic discount, the National Abortion Hotline, or both?

Clinic discountNational Abortion Hotline/National Abortion FederationPlanned Parenthood Justice FundI don't know

Have you been able to reach any other abortion funds for support?

YesNo

Name of fund

How much were they able to contribute toward your appointment costs?

Please enter a number

Total pledges from other funds

Remaining Balance: Total - (Your contribution + clinic discount + pledges from other funds)

If the amount you are in need of support with is different than the Remaining Balance above, please share:

Please enter a number

Practical support

LAAF can often provide additional direct support to folks traveling for care who are over 18.

Do you have additional support needs beyond funding for your appointment?

YesNo

Which of the following would you be interested in support with, if funding is available?

Please share details of the support you need

The following questions do not impact the funding we're able to provide.

Your responses do help us share about our work and reach more folks accessing abortion care, like you!

Your Preferred Pronouns

Your Age

Your Race/Ethnicity

Additional Race/Ethnicity

Are you currently working or a student?

Are there any children or adults under your care in your household? If so, how many?

If none, put 0

Do you have insurance or Medicaid through the state for yourself? (Select option that best represents your insurance status)

How did you hear about us?