Support Request Form

Step 1 of 12

Our Healthline hours are Monday through Friday, 10 am - 4 pm PT. All upcoming closures are listed on the Get Support page of our website.

The ACCESS Healthline exists to support Californians or those traveling to California who are seeking support with sexual and reproductive healthcare like abortion, gender-affirming care, birth control, prenatal care, and more.

Does the person needing support have a sexual or reproductive healthcare appointment scheduled or plan to order abortion pills by mail?(Required)

Yes

If you have not scheduled an appointment or have not yet connected with a provider that can mail you pills, please do not submit a request form. For more information about abortion care providers/clinics go to INeedAnA.com. To learn more about ordering abortion pills online, go to PlanCPills.org. If you need further assistance, please call the Healthline at 800-376-4636 or Linea en Español 888-442-2237.

ACCESS can provide procedural funding to these clinics. We can also provide procedural funding for Planned Parenthood Mar Monte health centers.

Once you connect with a provider and know the cost of care, please return to this form to continue submitting your support request. Thank you for your consideration!

Are you filling out this form for yourself or on behalf of someone else?(Required)

I am filling out this form on behalf of myself.

I am a healthcare provider, advocate, or friend filling out this form on behalf of someone else.

If you are not the person needing support, please fill out the following information.

In some situations, we must speak directly with the person needing support. We will ask for their contact information next.

Name of Person Filling Out Form(Required)

Please enter your first name and last initial (Example: Jane D.)

First Last

What pronouns do you use?(Required)

Please share your pronouns. What does this mean? We want to know how to respectfully refer to you! Pronouns are the part of speech used to refer to someone in the third person (Example: "Max is next door. They are borrowing a cup of sugar from their neighbor.")

If 'Not listed' - Please write your pronouns in the field below.(Required)

Relationship to Person Needing Support(Required)

If 'Not listed' - Please specify your relationship to the person needing support.(Required)

Is it okay to contact you for more information, if needed?(Required)

Yes, it is okay to contact me for more information.

No, do not contact me.

How would you prefer we contact you?(Required)

Call

Text

Phone(Required)

Email(Required)

Is it okay for ACCESS to leave a voicemail?(Required)

Yes, ACCESS can leave a voicemail.

Yes, it's okay to leave a voicemail but please use a codename.

No, do not leave a voicemail.

Our Healthline associates will use the codename Jane when leaving a voicemail.

Contact Information for Person needing support

The Healthline will use the following information to contact you to discuss support.

Name of Person needing support(Required)

What name would the person needing support like us to call them?

First Last

Date of Birth(Required)

What pronouns should we use?(Required)

Please share the pronouns of the person needing support (What does this mean?. We want to know how to respectfully refer to them! Pronouns are the part of speech used to refer to someone in the third person (Example: "Elle is next door. She is borrowing a cup of sugar from her neighbor.")

If 'Not listed' - Please let us know what pronouns to use.(Required)

Phone

Does this person have an email address?(Required)

If you are filling this form out on behalf of someone else and do not know whether they have an email address, please select 'No'.

Yes

Access to a secure, private email address is helpful if you need ACCESS's support with travel assistance like flights or lodging. You can create one for free if you do not have a secure email address.

Check out Proton Mail, where you can sign up for a free end-to-end encrypted email account.

Email(Required)

Enter Email Confirm Email

Where is the person needing support currently located?(Required)

The Healthline supports folks experiencing all kinds of housing situations. Please enter information for where the person needing support stays or spends most of their nights.

City State / Province / Region ZIP / Postal Code

Communication Preferences

The information collected in the next questions will help the Healthline better understand how to communicate with you and protect your privacy through the support process.

Preferred Language of the Person Needing Support(Required)

Healthline associates can provide support in Spanish and work with a translation service to communicate in many other languages.

If 'Not listed' - Please specify the preferred language(Required)

We typically use phone, text, and email to communicate. What methods are okay to use?

Call

Text

What contact method should we try first?

What is the best time to call?(Required)

The Healthline normally operates Monday - Friday, 10 am - 4 pm Pacific time. Our Healthline Associates will provide support and communicate within these hours.

10 am - 12 pm Pacific

12 pm - 2 pm Pacific

2 pm - 4 pm Pacific

Is it okay for us to leave a voicemail?(Required)

If "Yes," a Healthline associate will leave a voicemail if we do not get an answer when we call.

Yes

Should we use a codename or is it okay to say we are calling/texting from ACCESS?

All emails will come from an ACCESS email address.

Use a codename.

Say you're from ACCESS

If we should use a codename, what would you like us to say?(Required)

For example, "This is Jane calling regarding your doctor's appointment."

Support Services

Reason for contacting the ACCESS Healthline(Required)

Check all that apply.

Procedural Funding or Medication Costs

Transportation

Lodging/Hotel

Childcare

Doula and/or Emotional Support

Food/Meals

Aftercare/Comfort Products

Bill Support

Burial/Cremation

Lost Wages

Other (please specify)

If 'Other' - please provide additional information about the support needed.(Required)

Is the person needing support currently pregnant?(Required)

Yes

Does the person needing support know the date of their last menstrual period?(Required)

Select "Not Applicable" if the person needing support does not experience menstrual cycles, has irregular cycles, or needs non-abortion care.

Yes

Not Applicable

Last Menstrual Period(Required)

For folks who experience menstrual cycles, this information can help estimate the gestational age or how far along a pregnancy is.

If the last menstrual period is unknown, please estimate how far along the pregnancy is.(Required)

Example: For a pregnancy that is about 16 weeks and 3 days, please enter 16.3

Is the person needing support having an abortion?(Required)

Yes

What type of abortion procedure?(Required)

If the procedure type is not listed, please provide more information.(Required)

Appointment Information

ACCESS is able to provide procedural funding to these clinics. We can also provide procedural funding for Planned Parenthood Mar Monte health centers.

Clinic or Telemedicine Provider(Required)

This is a list of the clinics and providers that many of our clients use. If the clinic/provider is not listed, don't worry! Just enter the name of the clinic below.

If 'Not listed' - please enter the name and location of the provider below:(Required)

Date of Appointment(Required)

If there are multiple appointments, please enter the first or soonest appointment date. If you will order pills by mail, please enter the date you plan order.

Appointment Time(Required)

What time is the appointment scheduled to start? If there are multiple appointments, please provide the time of the first or soonest appointment.

Hours

Minutes

AM/PM

How much will the appointment and/or medication cost?

Please ask the healthcare provider for a good faith estimate of the total cost due for the appointment or medication.

How much funding or discount is the provider/clinic providing, if any?

Please also ask the healthcare provider if they offer financial assistance or screening for Medi-Cal/Medicaid and other state programs.

If eligible, how much funding is the National Abortion Hotline providing?

The National Abortion Federation's Hotline offers funding to some providers. Click here to learn more about the National Abortion Hotline and its eligibility requirements.

Are any other abortion funds/organizations providing financial or logistical support for procedural or travel costs?

Yes

If 'Yes' - List the name(s) of abortion fund/organization(s) providing support?

How much can the person needing support contribute toward the procedural or medication costs?

Medical Insurance

ACCESS does not work directly with medical insurance carriers. Our Healthline uses medical insurance information to help with support coordination and referrals.

Medical Insurance Carrier

If 'Not listed' - Please specify the medical insurance carrier(Required)

Is there a copay or deductible for the care needed?

Yes

Amount of Copay or Deductible

Demographic Information

The following questions are optional and used anonymously to inform all areas of our work at ACCESS. We use the demographic information we collect to help us better serve our communities and ensure that our services center identities most impacted by systemic oppression. The responses provided do not affect, in any way, the type or amount of support that we may be able to provide to someone. If you do not want to disclose or do not know this information, select 'Decline to say'.

Does the person needing support provide care or financial support to any dependents (children and/or adults)?(Required)

Yes, the person needing support has 1 or more dependents (children and/or adults).

No, the person needing support does not have any dependents.

Decline to state

Race or Ethnic identity(Required)

How does the person needing support describe their race or ethnic identity. Select all that apply.

African American/Black

Asian

Caucasian/White

Chicanx

Hispanic

Latinx

Middle Eastern

Mixed Race/Multi-Ethnic

Native American

Pacific Islander

South Asian

Ethnicity Queer

Decline to Say

Not Listed

If 'Not listed' - please specify race or ethnic identity in your own words.(Required)

Gender Identity(Required)

How does the person needing support describe their gender identity? To learn more about gender and identity, click here. Select all that apply.

Woman

Female

Man

Male

Agender

Bigender

Cisgender

Gender Fluid

Genderqueer

Gender Variant

Intersex

Non-binary

Third Gender

Transgender

Two-Spirit

Not Listed

Decline to Say

If 'Not listed' - Please specify gender identity in your own words.(Required)

How did you hear about ACCESS?(Required)

This information helps us keep folks informed about the support we provide.

If you selected "Not Listed," please provide additional information. If you were referred by a clinic or fund, please provide their name.(Required)

Is there any other information you would like us to know?