Use this form to plan your preferred method, clinic appointment and parental consent
We have a team of trained counselors that provide support for teens and parents to make informed decisions about sexual health and birth control. You can keep this form for your own personal use or you can send a copy of this form to Trust Her at info@trust-her.org.

When you fill out this action plan form, a copy of the plan or form results will be emailed you to you. The results are also stored securely. Trust Her does not use them to contact you or for any  other purpose.

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Email *
Name
(Optional)
Age
(Optional)
Questions for my doctor
Please add questions you might have for your doctor here.
Method(s) I'm considering
Clinic Information
You can find Dallas Clinics with Free and Low Cost Care here.
Appointment Date
MM
/
DD
/
YYYY
Appointment Time
Time
:
How I'm getting to the clinic
Plan your commute to the clinic.
How I'll pay
The clinic may ask for insurance, but if you don't have insurance, ask to see if you are eligible for free birth control from Trust Her. 
Friends or Family I can talk to about this
Write down who you can talk to among your family and friends.
Until I get my birth control, I can:
Make a plan here of what you can do until your appointment.
Preferred contact method
How to make an appointment?

  1. Find a clinic near you. Use trustherclinicfinder.org to find clinics with free birth control.

  2. Call the clinic to ask for an appointment. You can say: “Hi! My name is (add name) and I would like to make an appointment to get birth control." If you know which method you want, you can say, "I want to get [insert method here]." It's ok if you aren’t sure which method you’d like; a healthcare provider will walk you through the options. Don’t forget, you can ask for an appointment after school.

  3. Determine how you will pay. The clinic may ask for insurance, but if you don't have insurance, ask to see if you are eligible for free birth control from Trust Her.

  4. Before hanging up, if they don’t mention it, make sure to ask “Are there any documents I need to bring to my appointment?” You may need to an ID and an insurance card if you’re using it.

  5. Wrap up your conversation, write down the date and time of your appointment and arrange for transportation to get to your appointment.

    IF I’M UNDER 18...

    If you’re under 18, you will need parental consent for your method. Ask the clinic what they need to get consent - it could be a signed form, verbal consent over the phone, or they might need your parent to come with you.

My "What if" Plan
Make a plan if you're not able to get birth control for any reason.
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