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How did you hear about us?
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First Name
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Last Name
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Date of birth
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Gender identity
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Woman
Non-binary
Transgender
Man
Gender diverse or other
Pronouns
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She/her
He/him
They/them
Other
Prefer to not say
If other, please specify
Phone number
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Our call to you will come from a private number. If your phone cannot accept calls from a private number, please tell us if there are other ways for us to safely and confidentially call you.
Email
If you are seeking counselling support, please provide your residential address
Do you identify as being a First Nations person?
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Aboriginal
Torres Strait Islander
No
Are you from a migrant or refugee background?
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Yes
No
Do you require an interpreter? If so, which language?
Do you have a concession card?
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Yes
No
Do you have a Medicare card?
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Yes
No
Safe to call?
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Yes
No
Safe to leave voicemail?
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Yes
No
Safe to text?
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Yes
No
Safe to email?
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Yes
No
Are you pregnant?
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I am, or might be, pregnant
I am not pregnant
How many weeks and days is the pregnancy today?
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How was the length of pregnancy determined?
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Ultrasound
Blood test
Home pregnancy/urine test
Counted from the first day of their last normal menstrual period
Unsure
What kind of support are you looking for?
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Information about abortion and/or abortion providers
Support to make a decision about a pregnancy
Support to access an abortion
Information about adoption
Information about parenting
Post abortion support
Other
If other, please specify
Is there anything else that would be helpful for us to know?
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