This form provided courtesy of:
Life Dynamics Incorporated
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.