PATH Client Intake Form

The purpose of this questionnaire is twofold. First, we need some background information on you to help us understand how we can best help you. Secondly, answering these questions will begin an important process of remembering for you.  

The questionnaire may be fairly difficult to complete, as most women and men who have had an abortion experience would rather “forget” the details. Therefore, don’t try to finish it all in one sitting.  Grab a cup of coffee, sit down, pray and be in a place of privacy with no distractions.  

If it is too painful to go through this Intake Form by yourself, please let us know and, together, we will help you go through it.
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TODAY's DATE: *
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YOUR FIRST and LAST NAME:
 *
PHONE NUMBER: *
Please put your preferred contact number below in the space provided
Do we have permission to call or text your at this phone number? *
Please check which type of phone number the above number is below:   *
Required
STREET ADDRESS, CITY, STATE & ZIP CODE: *
Do we have your permission to send unassuming, discreet mail to you at this address? *
DATE OF BIRTH: *
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EMAIL ADDRESS: *
Please provide the best email address to contact you through.
Do we have your permission to email you at this email address? *
MARITAL STATUS: *
FAMILY: *
Do you have any children?  If so, please list name(s), age(s) and whether they are daughters or sons here:
HIGHEST GRADE OF SCHOOL COMPLETED: *
Required
ETHNICITY: *
Do you believe in God? *

Are you comfortable in a spiritual setting?

 *

Describe your current spiritual beliefs:

 *
Did you have any religious upbringing as a child? If so, please explain below.  *
Do you currently attend a church regularly? *
If so, what religion are you?   *
Required
If you attend church, what is the name of it? *
While you were growing up, did any of your family have any of the following problems? (check)
Alcohol
Drugs
Legal
Emotional Illness
Medical Ilness
Financial
Grandparent
Parent
Sibling
Total pregnancies you have had: *
Have you had any miscarriages? *
If "yes", how many and what are the approximate date(s) of the miscarriage(s). *
How many abortions have you had?   

NOTE:  If you did not have an abortion, please indicate by responding with "N/A" to this question and the next 4 questions
 *
Approximate date of abortion(s) *
Your age(s) at the time of the abortion(s) *
Type of abortion(s)?
Please check all that apply:
 *
Required
Where did you have your abortion(s)?
Please check all that apply:
 *
Required
Have you placed a child/ren for adoption? *
Do you have any children in foster care? *
Check any of the following symptoms that applied to you right after your abortion and any that you may still be experiencing:
Right After Abortion
Currently Experiencing
Guilt
Emotionally “numb”
Dreams/Nightmares/Triggers
Change in Relationships
Feelings of inferiority
Dizziness/Fainting
Sleep Disturbances
Can’t make friends or sustain friendships
Sexual problems
Preoccupation with abortion date
Preoccupation with due date
Relief
Depressed
Sadness
Anxiety / Inability to Relax
Cutting / Self harm
Suicidal thoughts
Sedatives
Alcohol/Drugs
Loneliness
Sense of Loss
Regret
Helplessness
Angry/Bitterness/Rage
Panic Feelings
Emotional Eating/Eating Disorder
Marital Stress
Fatigue
Shame
Inability to Forgive Others/Self
Fear of not being forgiven by God
Have you ever sought counseling for the pain or symptoms connected with your abortion? *
If "yes", were you helped? *
If "yes", what was beneficial in the help you received? *
Have you ever sought any other abortion recovery healing programs? *
If "yes", what program(s) were they?   *
If "yes", did you find it helpful? *
Please explain below. *

Are you currently seeing a psychiatrist, therapist/counselor and/or other mental health care provider? 

 *
Required

It may be beneficial for us to speak confidentially with your psychiatrist, therapist, counselor, mental health care provider and/or your doctor concerning your participation in PATH's abortion healing programs.  

Do we have your permission to contact them if needed? 

NOTE:  If your answer is "Yes," PATH requires a separate Consent to Release/Obtain Information to be completed and signed by you prior to us initiating any contact with your healthcare provider.

 *
Have you ever had medication prescribed (e.g. antidepressants) and/or been hospitalized in an effort to control any symptoms related to the abortion or other issues?   *
If "yes", please give details and list any psychotherapeutic medications that you are currently taking (both prescribed and over-the-counter): *
Did you feel you were adequately counseled and informed before the abortion? *
If not, what do you wish you had had in the way of counseling?  (Check all that apply): *
Required
At the time, who knew about your abortion? *
At the time, did you feel pressured/coerced into having the abortion?   *
Please explain in the space below *
What do you think would have been a SIGNIFICANT factor in helping you make a decision to keep the pregnancy?  (Check all that apply.) *
Required
Did your relationship with the male involved in the pregnancy continue after the procedure? *
If yes to above question, are you still currently with this same male who was involved in the pregnancy ? *
Was the relationship affected by the abortion?  If so, please describe how it was affected: *
Did you experience any physical complications resulting from the procedure (hemorrhage, infection, high fever, perforated uterus, intense cramping, incomplete abortion that required medical intervention and/or a second procedure, etc.)? *
If you experienced any physical complications resulting from your abortion, please explain in the space below *
Do you feel you have forgiven yourself? *
Do you think God has forgiven you for your abortion(s) *
State, in your own words, why you want to participate in PATH’s abortion recovery healing program(s)? *
How did you hear about PATH’s abortion recovery healing program? *
Required
Take a deep breath!  You have now completed this form!  Thank you!

PATH/Post Abortion Treatment & Healing
www.healingafterabortion.org
Confidential email:  programdirector@pathatl.com
Phone:  404-717-5557
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