Directory Enrollment Form

Directory Enrollment Form

We look forward to featuring your organization in our directory of life-affirming assistance providers. Please provide the information below so we can move forward with your listing. Our team will review your information and be in touch if further information is needed before publication. Please don’t hesitate to contact us if you have any questions.

Company

This field is for validation purposes and should be left unchanged.

Contact Info

Name(Required)

First Last

Your Email to receive Her PLAN communications(Required)

Org Email to display on Directory (This can be same or different than above email)(Required)

Company or organization name(Required)

Website or Social Media URL(Required)

Address(Required)

Street Address City State ZIP Code

Your Phone number for Her PLAN communications(Required)

Phone number to display on Directory (This can be same or different from above.)(Required)

How did you hear about Her PLAN?(Required)

Her PLAN Contacted Me

An Event I Attended

Media Article/Video

Another Provider

A Church

Internet Search

Other (Please explain below)

Please Explain:

Please select the options below that most closely align with the price(s) you charge:(Required)

Free

Discounted/Negotiable

Sliding Scale

Accepts Medicaid

Market

Other price details

Price details that help directory users, such as which service goes with which price point, specific service costs, insurances accepted, qualifications for discounts, etc.

Services

How would your services benefit a pregnant/parenting woman or family with children under age 2 (whether or not they are your only demographic)?(Required)

Are you a Pregnancy Center? (pick one)(Required)

Yes

Would you like the optional "leaf icon" to accompany your entry? To qualify, please check "yes" to pledge not to provide, refer for, or offer: hormonal contraception; barrier methods of preventing pregnancy; sterilization; in-vitro fertilization; or artificial insemination.

Yes

The following questions will help us provide details about your services in the Her PLAN directory.

Please check the box for each service that you offer.(Required)

Lay/Peer Counseling or Client Advocacy

Pregnancy Tests

Baby Boutique

Maternity Boutique

Abortion Recovery Support

Transportation to Center via Vouchers/Uber Health/Paying for Cabs

Brightcourse/Earn While You Learn

Other Pregnancy/Parenting Class (Please Describe Below)

Prenatal Vitamins

Describe your curriculum or program (include whether it's online, in person, or both and how long the program lasts)

Which Brightcourse sessions do you frequently offer?

Other Pregnancy/Parenting Class Description

Please check the box for each medical service that you offer.(Required)

Mobile Ultrasound Unit

Limited 2D OB Ultrasound

Limited 3D/4D OB Ultrasound

Urine STD Testing

STD Treatment

Abortion Pill Reversal (APR) Consulting Center (no in-house prescriber)

None of the above

For organization or individuals routinely providing rides or having a mobile unit, we look for automotive insurance. Do you carry automotive insurance?

Yes - We have automotive insurance

No - We don't carry automotive insurance

Other

If you selected no or other, please explain

If applicable, please include all addresses where your mobile unit regularly parks and include those details. If your unit location frequently varies or is flexible, please indicate a radius traveled from a central address.

Testing for Whom?

For Pregnant Clients Only

Open to the Community

Testing for Whom?

For Pregnant Clients Only

Open to the Community

Tell us anything about these programs that would help us improve your directory listing. Feel free to link to your relevant web pages.

Do you have any other services not yet checked?(Required)

Yes

Please check the box for each additional non-medical services that you offer.

Please check the box for each additional medical service that you offer.

Please describe the expanded services checked above in more details, or link to webpage explanation.

Please check the box next to any of the following networks, brands, or certifications that apply to you.

Care Net

Heartbeat Int.

My Choice Network

NIFLA

Obria

Affiliated with Another Network

Not Affiliated with Any Network