Abortion Assistance Intake Form

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Thank you for reaching out to Planned Parenthood of Tennessee and North Mississippi. Our doors are open and we are committed to helping you get the care that you need!

If you need help with the next steps in getting an abortion, please complete the following form and someone will reach out to you within 48 hours. Please note that the call may come from a private or blocked phone number.

We recommend that you schedule your abortion before reaching out to us. In order to identify and schedule an appointment with the provider that makes the most sense for you, use the following websites:

https://www.abortionfinder.org/

https://www.ineedana.com/

https://www.plannedparenthood.org/ (for out of state Planned Parenthood locations)

If you are unsure how to identify a provider, please use this form to reach out.

We strive to protect your privacy and will maintain all of this information as confidential. However, if you are not using a personal, secure device or have any concerns sharing this information online, please call us at (866) 711-1717.

Have you made an abortion appointment outside the state? *

Yes

No (Please use the above websites to identify and schedule an appointment with your preferred provider before completing this form, if you need assistance in scheduling select the option below)

Need Assistance

First Name *

Preferred Pronouns *

She/Her

He/Him

They/Them

Other:

Age *

Phone Number (You may be contacted by a private or blocked number) *

Privacy Concerns *

Safe to leave voicemail and say "Planned Parenthood"

Safe to leave voicemail and say "Patient Navigator for Assistance"

DO NOT Leave voicemail messages (if this is the case, will try to contact 3 times)

Current Zip Code

Last Menstrual Period (LMP) (if unsure, leave blank)

YYYY

How many weeks today? (if unsure, leave blank)

Confirmed Pregnancy? *

Ultrasound

Pregnancy test (home)

Physicians office

Type of Assistance? (select all that apply)

Finding a Provider

Travel Assistance

Financial Assistance

Other:

Submit

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