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COUNSELING QUESTIONNAIRE   (OPTIONAL)
This questionnaire will help your counselor identify what things are most important for you to discuss prior to the procedure.

  1. What is your name (1st name and initial OK)?
    First:    MI:    Last: 

  2. What is your E-mail address?


  3. Who will be here with you on the day of your procedure?
    First Name:   Relationship: 
    Do you want this person in the counseling session with you?  Yes  No
    Dose this person want to speak with someone privately?  Yes  No

  4. On a scale of 1 to 10, 1 being the easiest and 10 being the hardest, how difficult was it for you to make this decision?
    1   2   3   4   5   6   7   8   9   10 

  5. Who is supportive of the decision to end your pregnancy?


  6. What are your thoughts about ending this pregnancy?


  7. The following are some feelings that women describe experiencing when making this decision. Check words that describe how you feel:

    sad
    confused
    resolved
    comfortable
    helpless
    happy
    scared    		 selfish
    disappointed
    angry
    relieved
    trapped
    grieving
    confident    		 numb
    irresponsible
    lost
    guilty
    ashamed
    peaceful
    strong

    Other: 

  8. Please check what concerns you most about this decision: 
    a. Not sure of my decision to have an abortion
    b. Is this confidential?
    c. My relationship with my partner
    d. The protesters
    e. Wondering how I'll feel emotionally afterwards
    f. Is this going to hurt?
    g. Possible effects on future pregnancies
    h. Possible complications during and after
    i. My relationship with my family
    j. My religious teachings or spiritual/moral beliefs
    k. Birth control afterwards
    l. What literature or pamphlets do you have?
    m. Need more information on how the abortion procedure is done
    n. Other 

        


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