I Need Support

Patient Contact Information

Patient First Name

Patient Last Name

Patient Preferred Name

The name they go by if different than the name provided above.

Patient Preferred Pronouns

Patient Date of Birth

We use your date of birth to make travel arrangements and confirm your appointment with the clinic.

Relationship to Patient Relationship to Patient

Name of Representative

First

Last

Phone Number

View our privacy policy. If you do not want to receive calls or messages from us or if it those are unsafe options for you, please indicate that on the form below. Also, you can opt out of texting at any time by sending a text "do not need support" or "stop."

Email

The Cobalt Abortion Fund intake team will send emails with status updates from a no-reply email address to the email provided. If you are unable to receive emails due to a safety concern, please do not submit this intake form and reach out to the clinic you are scheduled at for further assistance.

Preferred Contact Method

Email

Phone

Text

Cobalt Abortion Fund primarily uses a phone-based intake system for funding. If phone calls and/or texts are not a safe option for you, please make note of that when submitting this form and we will email you instead. If phone calls, texts, and emails are all unsafe options for your situation, please do not submit this intake form and reach out to the clinic you are scheduled at for further assistance.

Is it safe to call?

Yes

No

Can we leave a voicemail?

Yes

No

Can we send a text message to the phone number provided above?

Yes

No

By selecting "Yes," I agree to receive communications by text message related to general inquiries From Cobalt AF. You may opt out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy ( https://cobaltaf.org/privacy-policy/ ) to learn how your data is used. By selecting "Yes", you are consenting to accept text messages from Cobalt Abortion Fund and understand that data and messaging rates may apply. To opt-out of texting at any point in time, reply "STOP." For help with SMS, reply "HELP."

Patient Situation

Answering these questions to the best of your ability can help us respond more quickly to your request.

City

City where you live

State

State where you live

Number of Weeks Pregnant

Numbers only, please.

Have you scheduled an appointment with a clinic?

If you have not yet scheduled an appointment, you can visit our services page for providers in your area.

Appointment Date

Name of Clinic Name of Clinic

Which of our partner clinics do you have an appointment with? If the clinic is not listed here, select, "Other."

Select Your Planned Parenthood Location

Estimated Cost of the Procedure

Numbers only, please.

What kind of support do you need?

Procedural

Practical

Procedural support refers to the cost of the abortion procedure itself. Practical support means you need help with things like lodging, food, and transportation. If you need help with both, then select both options.

Message

Please provide more information about your situation and the kind of support you need.

Account Name

Captcha

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Patient Contact Information

Patient Situation

Our Fund

Patient

Provider

Donor

Your Story