Application for Assistance

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. There are no circumstances surrounding your pregnancy that will make you more or less deserving of assistance. 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. 

If your internet access is limited and/or you are having trouble using our online application, call or send us an email and let us know you need a paper application.

 

Please complete the form below

Tell Us About Yourself
Name *
Name
Address *
Address
Phone *
Phone
How would you like us to communicate with you? *
We will only contact you by what you select. You can select more than one. If you tell us to text you only, we won't call or email.
Where is your appointment? *
When is your appointment? *
When is your appointment?
How many days will you be here? *
Is is safe to call you? *
Race
Select any that apply
Are you a student? *
Are you safe at home? *
Does your spouse, partner, or person(s) with whom you are in an intimate relationship 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
Tell Us How We Can Help You
What type of assistance do you need while in Albuquerque? *
How will you be getting to Albuquerque? *
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.
Have you ever... *
Check all that apply
We can only accommodate one support person.
Tell Us How To Make You Comfortable
Do you smoke cigarettes, cigars, or use chewing tobacco? *
Vegetarian? *
Just A Couple More Questions
Would you say that you are a religious person?
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.
Are you getting assistance from NAF?
If you're not, ask the clinic if you qualify for assistance from the National Abortion Federation.
If yes, please tell us the name of the fund(s) helping you so we can make sure we're working together to get you the best help.
Would you like to know more about the National Network of Abortion Funds?
We are part of a national and international network of funds supporting access to abortion care.
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.
Acknowledgement