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This is a secure form. Your privacy is critically important to us, and your information will not be shared outside of our organization. Please only submit this form once. A case manager will be back in touch within 24 hours via phone. There is no need to call us as well!

For prompt assistance, please provide your appointment details as we will prioritize based on this information.

Please select your language.

What is your preferred language?

First Name

Last Name

What are your pronouns?

What phone number is best for us to reach you? (Numbers ONLY)

What is your email?

When we call, is it OK to identify ourselves as the DC Abortion Fund / DCAF? (Please note: We may call you from a blocked number.)

YesNo

What city do you live in?

What state do you live in?

What country do you live in?

Appointment Information

Do you have a scheduled an appointment for your abortion?

YesNo

How far along in weeks are you in your pregnancy? An estimate is fine. (if unknown, put 0)?

What clinic have you made an appointment with?

When is your appointment (MM/DD/YYYY)? Leave blank if date is unknown.

If you are scheduled at a clinic that is NOT a Planned Parenthood, it’s important to see if you qualify for national funding. Have you reached out to the National Abortion Hotline at 1-800-772-9100? If not, please call the National Abortion Hotline at 1-800-772-9100.

YesNo

How much was the National Abortion Hotline able to give you?

If you are scheduled at a Planned Parenthood clinic, the clinic should have screened you for funding assistance. Did you get offered that funding? If not, please call the Planned Parenthood that you are scheduled at and ask them specifically to screen you for Justice Funding.

YesNo

How much were they able to give you?

Have you reached out to any other local abortion funds? Select all that apply.

Click on one of the Abortion Funds to select it as an option. To select more than one, hold down the control (Ctrl) or command (Cmd ⌘) key and click on the other names.

What is the total price of the procedure, as quoted by the clinic?

Do you need any practical support such as travel, hotel, local rides in order to get to your appointment? Please note: DCAF does not offer this type of support, but we are happy to connect you with local or national organizations who do!”

YesNoUnsure

Can we send you a post-intake feedback survey?

YesNo

What is the best way to reach you for the feedback survey?

CallTextEmail

I’m a parent	I’m a single parent
I have HIV	I have a disability
I identify as LGBTQIA+	I am unhoused
I am a sex worker	I am a student
I am an immigrant or migrant	I am a drug user
I don’t have health insurance	I am a DC native

Woman	Man
Transgender	Cisgender
Non-binary	Genderqueer
Two Spirit	Unknown

Page 1

This is a secure form. Your privacy is critically important to us, and your information will not be shared outside of our organization. Please only submit this form once. A case manager will be back in touch within 24 hours via phone. There is no need to call us as well!

Page 2

The questions below are optional and will not impact our ability to fund you, but do help us better serve and understand our callers.