Post-Abortion Questionnaire

Office Hours:

Monday
9am - 7pm

Tuesday, Wednesday,
Thursday
9am - 5pm

Friday
9am - 1pm

526 W. Wisconsin Avenue, Appleton, Wisconsin
(920) 731-4354
Pregnancy Testing and Resource Center

Post-Abortion Questionnaire

Have you had to cope with the pain of an abortion? Do you need to talk to someone about how your experience has affected you? We’d like to help. We are here to help you heal.

The information on this questionnaire will be kept confidential. We give personal consideration to each and every questionnaire that is sent to us. It helps us serve you more promptly if you provide some insight into your situation before we email a response to you.

We do not share this information with anyone without your permission. Please answer as many of the questions as you can. You may leave unanswered questions blank.

Name/Nickname:

Email Address:

Age:

Do you feel like your abortion has changed you?

If yes, how has it changed you?

If asked, would you advise someone else to have an abortion?

Did you have an abortion even though you felt it was wrong?

Did you feel pressured into having an abortion?

If yes, how did you feel pressured?

If you feel that someone you knew pressured you, how has your relationship changed?

Do you feel like you have been alone in the pain of having an abortion?

Select all that apply or have applied to you since your abortion:

Do you experience feelings of emotional numbness during emotional circumstances?

Have you experienced a change in your spiritual beliefs since your abortion?

If yes, how have your feels changed?

Have you hidden your abortion from anyone?

Have you hidden your feelings about your abortion from anyone?

Have your feelings changed your relationships with men?

If yes, explain how your relationships with men have changed:

Have you purposely tried to avoid any situations that remind you of your abortion?

If you have answered "yes" to any of the above questions, you may be experiencing post-abortion syndrome. If you would like to tell us your story, it will be kept confidential:

Would you like to receive an email response from a volunteer support client advocates?