Stories
Home

Real Options

Stories
Home

 

Name *
Cell Phone *
Address
Gender *
Age
Ethnicity
What race best describes you?
Practicing Religion
How did you hear about us? *
How may we contact you (select all that apply?) *
Reproductive losses you have experienced (select all that apply): *
Date of your most recent abortion:
Types of abortion(s) you have had (select all that apply):
Do you currently have children that you are not caring for? (select all that apply):
Emotionally-speaking, I feel good most days. *
During the past month, I have felt down, hopeless, or depressed. *
During the past month, I have experienced the following symptoms (check all that apply): *
During the past month, I have felt satisfied with the quality and intimacy of my relationships with my partner, friends, and/or family members. *
During the past month, my mood would most often be described as angry, irritated, frustrated *
During the past month, I have been able to accomplish life's demands that are expected of me (school, work, parenting, household tasks, hygiene). *
Are you currently having suicidal thoughts, or have you in the past? If you are having suicidal thoughts now, please call the suicide hotline at 988. *
Have you received help for your losses through any of the following services? *
Are you currently in counseling or seeing a professional? *
If you are seeing a professional, do they support your participation in this group? NOTE: This group does not replace professional help you are receiving. *

Thank you for registering for the Unraveled Roots support group. Someone will contact you with more information about the group.

Back to Top