Request support for your abortion

Please read this form carefully and entirely. Fill out each question to the best of your ability.

We may use your name and birth date to confirm your appointment with a clinic and to coordinate with other abortion funds. Your personal information will never be shared outside of this.

We are currently out of funding for abortion pills. If you need support, we can help refer you to organizations that can help, or to providers that offer free/low cost medication.

We will do our best to respond to you within 2-3 days (48-72 hours). Our hours are 9:00-5:00 mountain time, Monday through Friday. Please know that our intake team includes volunteers.

If you are interested in or seeking abortion pills, we recommend first checking PlanC.com to find a provider for abortion pills. Abortion pills can be mailed to all 50 states.

We have limited funding for abortion pills. We can help you connect with providers that offer free and low cost abortion pills. If you’re not needing medication, our team can also help you navigate between in-person providers that fit best for you.

If you are having technical difficulties filling out this intake form, give us a call and leave a detailed voicemail. We won’t return calls that do not leave a voicemail. ‪(720) 432-1583‬

Basic Information

Name

We will keep your information safe and private. If you are comfortable, please provide your first and last name. If not, just first name is okay!

Pronouns

Please list your pronouns: she/her, he/him, they/them, she/they, he/they, ella/ellas, el/ellos, etc.

Phone

(###)

###

####

Date of Birth

YYYY

What state do you live in?

What is the best way for us to contact you?

Select all that apply. If text is listed as an option, CDP will contact you via SMS. If text is not an option, please select another form of contact.

By text

By phone call

By email

Another way (please specify in the write-in box at the end of this section)

Can we leave a voicemail?

Do you need support in a language that is not English?

Abortion Care Information

How far along in pregnancy are you (in weeks and days)?

Please provide us the weeks and number of days, if possible. If you are unsure, you can calculate an estimate using the first day of your last period. Pregnancy Calculator: https://americanpregnancy.org/resources/pregnancy-calculator/

Which provider are you getting care from?

Let us know which clinic or which provider will be overseeing your care. Below is a list of clinics that we typically work with. If your clinic is not listed below, please select Other and use the write in box. An appointment will be required to receive financial support. If you do not have an appointment and are unsure of where you should schedule, please fill out this form and we will provide recommendations for clinics. Some questions below may not apply to you if you have not scheduled an appointment.

If provider not listed, please tell us which provider you are getting abortion care from

Abortion Type

If you're not scheduled for an appointment yet, list the type of abortion you'd like to have.

What is the date of your appointment?

If you are requesting medication through an online provider and do not have to schedule an appointment, you can leave this blank

YYYY

What is the time of your appointment?

Please list the date and time of your procedure or appointment, in mountain time. If we are coordinating rides, we will help schedule rides based on the information you provide to get you there on time.

Hour

Minute

Second

Services Request

Do you need help paying for your abortion?

We have limited funding and cannot guarantee support. We recommend reaching out to the National Abortion Federation, Cobalt Abortion Fund, and funds from your home state (if traveling).

Do you need help booking and paying for flights to and from your appointment?

Do you need a place to stay for your abortion?

Do you need volunteer rides to/from appointments?

Do you want support from an Abortion Doula?

An abortion doula can provide physical, emotional, and informational support throughout your abortion process. The intake coordinator that reaches out may or may not be the same as your abortion doula. Our abortion doulas are volunteers and we cannot guarantee availability. Our doulas are Colorado-based and can provide virtual support to anyone, regardless if you live in Colorado. Select all that apply.

No, I do not want support from an abortion doula

Yes, I would like a doula to sit in the clinic with me

Yes, I would like a virtual doula (over text, phone, or email) to talk to about my abortion

Additional Information

Is there anything else you would like to share with us?

Is there any other support that you need to have a safe and successful abortion? Please note that we will only send direct funding for gas, childcare, and travel expenses after you have had your abortion.

Request support for your abortion

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