NM Religious Coalition for Reproductive Choice

Application for Assistance

Officeassistant@nmrcrc.org

Please treat our staff and volunteers with respect and dignity by answering truthfully and completely, so that we can provide the best care for you. Our work is grounded in religious principles of love and acceptance of all people, and we believe that together we can end the shame and stigma associated with abortion.

Tell us about yourself

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

If you live in Texas, you must contact Fund Texas Choice at http://fundtexaschoice.org/need-help/ before we can help you.

Your Age

*

Can you tell your parents you need an abortion?

Yes

No

Do you live in a state that requires you to tell your parents?

Some states requires teens to tell their parents or get their parents permission. New Mexico does NOT.

Phone

*

Email

*

What is the best way to communicate with you?

*

Call/voicemail

Text message

Email

I won't have a phone with me

Where is your Appointment?

*

Southwestern Women's Options

University of NM Center for Reproductive Health

Planned Parenthood of NM

Whole Woman's Health, Las Cruces

I don't know

When is your appointment?

*

DATE

*

TIME

How many days will you be here?

*

2

3

4

Is it safe to call you?

*

Yes

No

Is there anyone who should NOT know you are pregnant or having an abortion?

*

Race

Any that apply

African American

Asian

Hispanic /Latin@

Native American/Indigenous

White

Other

Do you have a job?

*

Or your parents, if you are still living with them. Or your partner/spouse if you don't work and live together.

Full time

Part time

Unemployed

Monthly Income?

*

Other Income

Do you, or your family receive any government assistance?

Food Stamps

TANF/Cash Assistance

WIC

Social Security

Disability

Unemployment

Are you a student?

*

Are you safe at home?

Does your husband, partner, or boyfriend hurt you or your children, threaten to hurt you or your children, or say mean things to you or about you or your children? Do they threaten or hurt your pets?

Are you homeless?

Tell us about your pregnancy

Are you pregnant because you were raped or forced to have sex?

It is against the law for a husband, live-in partner, or boyfriend to force you to have sex or have sex with you when you can't say yes or no.

How many weeks pregnant are you?

*

Do you have any medical problems with this pregnancy?

*

Birth Control

Were you using any type?

What Kind

birth control

Tell us how we can help you

What type of assistance do you need?

*

While in Albuquerque

Rides to and from clinic

Overnight stays

Meals

Something else

Traveling

*

How will you be getting to Albuquerque?

Driving

Plane

Bus

Train

Other

Travel Details

*

IF YOU NEED A VOLUNTEER TO PICK YOU UP, WE MUST HAVE THE NAME OF YOUR AIRLINE AND FLIGHT #, OR BUS/TRAIN # AND ESTIMATED TIME OF ARRIVAL!

Who is traveling with you

*

We can only accommodate one support person.

Tell us how to make you comfortable

You'll be staying in the home of one of our volunteer families. What do they need to know to make sure you are comfortable?

Smoker?

*

Do you smoke cigarettes, cigars, or use chewing tobacco?

Yes

No

e-cigarette

Vegetarian

Allergies?

Are you allergic to any food, pets, soap, etc?

If so what kind?

Do you have any religious dietary restrictions?

Do you have any medical dietary restrictions?

What else should we know?

Just a couple more questions

Would you say that you are a religious person?

Would you like to talk to a Minister, Pastor or Rabbi about your decision to have an abortion?

All of our religious counselors are pro-choice, no shaming.

Would you like to know more about the Religious Coalition for Reproductive Choice?

We have affiliates in other states and in Washington, DC. Would you like to know more about who we are and what we do?

Are you getting assistance from NAF?

If you're not, ask the clinic if you qualify for assistance from the National Abortion Federation.

Are you getting assistance from your local abortion fund?

Please tell us the name of the fund(s) that is helping you so we can make sure we're working together to get you the best help.

Click here to find the National Abortion Federation Hotline.

Click here to find the National Network of Abortion Funds.

Would you like to know more about the National Network of Abortion Funds?

We are part of a network of funds in other states and internationally. Would you like to know more about who we are and what we do?

Do we have your permission to share the information on this form with other abortion funds?

*

We will only share this information if we think another fund can help you along with our help or help you better than we can.

Yes

No

If you answered yes, type your initials here.

*

Please type your legal name in the box below to say that you give us permission to share your information with our volunteers and the clinic.

*

Date

(mm/dd/yyyy)