Unraveled Roots Form

Age

Ethnicity

Hispanic Non Hispanic

What race best describes you?

Practicing Religion

How did you hear about us?

How may we contact you?

Call Text Email Mail

Reproductive losses you have experienced (select all that apply):

Abortion Miscarriage Stillbirth None of the Above

Date of your most recent abortion:

Types of abortion(s) you have had (select all that apply):

Abortion Pill (chemical or medical abortion, not Plan B) Surgical

Do you currently have children that you are not caring for? (select all that apply):

Yes, due to infant/child loss Yes, due to placing for adoption Yes, due to children removed from home None of the above

Emotionally-speaking, I feel good most days.

During the past month, I have felt down, hopeless, or depressed.

During the past month, I have experienced the following symptoms (check all that apply):

During the past month, I have felt satisfied with the quality and intimacy of my relationships with my partner, friends, and/or family members.

During the past month, my mood would most often be described as angry, irritated, frustrated.

I have been able to accomplish life's demands that are expected of me (school, work, parenting, household tasks, hygiene).

Are you currently having suicidal thoughts, or have you in the past? If you are having suicidal thoughts now, please call the suicide hotline at 988.

Have you received help for your losses through any of the following services?

Are you currently in counseling or seeing a professional?

Yes No

If you are seeing a professional, do they support your participation in this group? NOTE: This group does not replace professional help you are receiving.

Yes No

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