After-Abortion Support & Care (AASC)
The purpose of this questionnaire is twofold. First, we need some background information on you to help us better understand how we can best help you. Secondly, answering these questions will begin an important process for you of remembering. This questionnaire will be fairly difficult the longer it has been since your abortion(s), as most post-abortive women would rather “forget” the details. Do the best you can.
Name(Required)
Address
Consent
Consent
Is it OK to contact you? (Check as many methods as apply.)
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Race/Ethnicity
How important is it for you to receive help in dealing with your past abortion(s)?
Are you presently affiliated with any religious organization?
How would you describe the extent of your involvement?

While you were growing up, did either of your (step)parents, grandparents or siblings have any of the following problems? Check off all that apply.

Alcohol
Drugs
Legal
Financial
Medical Illness
Emotional Illness
Financial

ABORTION HISTORY: Almost 50% of women who abort today have had two or more abortions. We understand that many details may be difficult to remember – especially if you had more than one abortion. Do the best you can and you will remember more as the group progresses.

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Marital status at the time
Where was the abortion performed?
Have you ever sought counseling for the pain connected with your abortion?
Do you feel you were adequately counseled and informed before the abortion?
Have you ever had medication prescribed (i.e. antidepressants) and/or been hospitalized in an effort to control any symptoms?
If no, what do you wish you had received in the way of counseling? (check all that apply)
At the time, did you feel pressured into having an abortion?
What do you think would have been a SIGNIFICANT factor in helping you make a decision to keep the pregnancy? (check all that apply)
Did your relationship with the male involved in the pregnancy continue after the procedure?
Did you experience any physical complications resulting from the procedure? (hemorrhage, infection, high fever, perforated uterus, intense cramping, incomplete abortion, etc.)
Would you have this abortion again?
If you are a Christian, do you feel God has forgiven you for this abortion?
Do you feel you have fully accepted His forgiveness for yourself?

Using the following guide, please evaluate those emotional, behavioral and physical responses you have experienced in relation to your abortion(s). 0 = Have Not Experienced 1 = Mild 2 = Moderate 3 = Extreme

Anxiety/Panic/Nervous Tension
Emotional Numbness/Shock
Grief/Loss/Sorrow/Sadness
Regret/Guilt/Shame
Loneliness/Isolation/Difficulty Making Friends
Feeling “Branded” - As if Other People Can Tell
Alienation/ Feeling Different From Other People
Depression/Hopelessness
Inability To Trust Men, Doctors, Others
Inability to Trust Myself or My Decisions/Self-Doubt
Anger/Rage
Feelings of Having Been Victimized
Fear of Punishment
Dreams/Nightmares/Difficulty Sleeping
Fear or Discomfort With Sex or With Sexuality
Feeling Uncomfortable With Infants/Children/Pregnant Women
Depressed/Sick or Accident-Prone Around Anniversary Dates
Flashbacks or Hallucinations Related To The Abortions(s)
Difficulty Concentrating
Secrecy/Difficulty Telling Others About Abortion(s)
Difficulty Forgetting and/or Difficulty Remembering
Fear of Infertility, Miscarriage or Pregnancy Loss
Feeling Crazy
Thinking A Lot About The Aborted Child
Crying Too Much or Too Easily/Inability to Cry
Figuring How Old Baby Would Be/Sadness Seeing Kids that Age
Difficulty Bonding With or Over-Protective of Other Children
Eating Disorders
Increased Drug or Alcohol Use/Addiction
Suicidal Thoughts/Attempts
Fatigue/Tiredness
Repeat Pregnancy Soon After Abortion (Regardless of Outcome)
Longing For A Baby
Marital Difficulties/Marital Stress
Need To Be In Control
Break Up With Father of Aborted Baby
Promiscuity (Many Sexual Partners)
Preoccupation With Abortion Date or Due Date
Fear of Failure
Lowered Self-Worth/Inferiority Feelings

First Choice Women’s Resource Centers are staffed by volunteers who have been trained to facilitate the After-Abortion Support groups, a faith-based program. These volunteers may or may not have degrees in counseling or be licensed by the State. Consequently, the AASC groups are not intended as a substitute for professional counseling. Referrals will be made for professional counseling upon request or when deemed appropriate by the leader(s) of the support group. We offer information, counsel and support. Participation in the AASC group is free.

All information on this intake/disclaimer is confidential and is only for the use of the leader/co-leader of the AASC program and the Director of First Choice Women’s Resource Centers. There are certain circumstances in which we would be compelled to break confidentiality: if we believe you are at a high risk for suicide; if you are under 18 and are a victim of sexual/physical abuse; if we believe you intend to harm another person; or if we believe you are in need of hospitalization for a psychiatric disorder. Additionally, the information on this intake form will probably be used for research. Please know that any information taken from this form will be used WITHOUT YOUR NAME ATTACHED to ensure your complete privacy.

I have read and understand the above. I also promise to keep anything and everything that is said during the AASC group sessions completely confidential.

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