Patients and Providers: Tell Us Your Story!

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Have you or members of your family been denied reproductive health care or end-of-life services by a religiously based medical facility? The ACLU believes that everyone in Washington has the right to receive health care that is not restricted by the religious beliefs of others. As more and more hospitals merge, the ACLU is concerned that reproductive health care, end-of-life services, and services to LGBT individuals are being limited based on religious views. We are seeking information to better understand the extent of the problem in our state.

The ACLU of Washington would like to hear from patients and providers about your experiences accessing or providing reproductive and end-of-life health services, counseling, and referrals in Washington state. We also would like to hear about any experience of discrimination on the basis of sexual orientation or gender identity and expression in seeking or accessing health care services, counseling, or referrals in Washington state. For examples of services or information that may be restricted or denied please go to https://www.aclu-wa.org/healthcarerestrictions

Your responses will be kept confidential. Thank you for sharing your experience!

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First Name *

Last Name *

Email *

Mailing Address:

City

State

Zip

Phone Number *

Are you a patient or a provider *

Patient

Provider (e.g., doctor, nurse)

Friend or Family Member of Patient

If you are writing on behalf of another person, please list:

Name of person

Relationship to person

* To follow up on complaints of this nature, we may need to gather more information from you. Please provide your contact information so that we may contact you on a confidential basis if we need more information.

Privacy: We respect your privacy and will only use the contact information you provide to contact you regarding the complaint you submit today. Other than that, we will never send unsolicited email, or share personal information you submit. For further information, see our privacy statement.

Disclaimer and Notice: This form does not give legal advice, and you should not rely on it as legal advice. This form is not an offer by the ACLU of Washington to represent you. We cannot promise you that the information you provide will lead to any specific action on the ACLU of Washington's part. Once you complete the survey, the ACLU of Washington may not do anything - including contact you - about your situation.

Confidentiality: Thank you for sharing your story. We'll keep the specific details of your story confidential unless we contact you and get your permission to share it. However, we may generally categorize and share with others the types and numbers of reports we have received. For example, to help show the extent of restrictions on health care services resulting from hospital mergers and affiliations, we may disclose the number of reports we receive. We will never, however, use your name, address, or other identifying information without contacting you and asking permission.

Agreement *

I Agree

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