Name *

First Name

Last Name

Phone

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###

####

How much are you having trouble accepting your loss?

Mark only one

Not at all

Somewhat

A lot

How much do your emotional responses interfere with your life?

Mark only one

Not at all

Somewhat

A lot

How often are you having mental images of your loss or anything that reminds you of your loss?

Mark only one

Not at all

Somewhat

A lot

Since your loss, how much are you having difficulty connecting with other people, including family, friends or a partner?

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Not at all

Somewhat

A lot

What type of abortions did you experience?

Mark all that apply

Surgical

Medication (Pill Abortion)

Using the date ranges, how long ago was your most recent abortion?

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1 week or less

2-5 weeks

6-12 weeks

4-11 months

1-5 years

6-10 years

11+ years

Have you attended counseling, abortion healing or any other programs to address the impact abortion had on you?

Please know these groups are not led by a therapist and are not designed to replace your therapist or be used for therapy. We highly recommend that if you in the care of a therapist, please let him or her know. Mark only one

No

Yes