This form provided courtesy of:

Life Dynamics Incorporated

Denton, Texas

Terms of Use:

Life Dynamics Incorporated is the legal copyright holder for this document and grants permission for it to be downloaded and used by pro-life pregnancy counseling centers. Those who print this document are agreeing to the following conditions:

  • The form will not be given to the client for her to fill out but will, instead, be filled out by a counselor at the center. The client will be given a copy of the completed document after she has signed it.
  • The counselor agrees to immediately begin making the notifications called for in the document.
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