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Intake Form - English

Patient Contact Information

The name they go by if different than the name provided above.
We use your date of birth to make travel arrangements and confirm your appointment with the clinic.
Name of Representative
Name of Representative
Preferred Contact Method
Is it safe to call?
Can we leave a voicemail?

Patient Situation

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

City where you live
State where you live
Numbers only, please.

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

Which of our partner clinics do you have an appointment with? If the clinic is not listed here, select, "Other."
Numbers only, please.
What kind of support do you need?
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.
Please provide more information about your situation and the kind of support you need.

Our Fund

Our abortion fund is 100% donor funded and the only independent fund of its kind in the state of Colorado. If you would like to make sure no person experiences a financial burden when it comes to abortion,

Please consider a gift to the the Cobalt Abortion Fund.