Couple-Focused Services in Publicly Funded Family Planning 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1: Applicant Information. Fill in your last name, first name, middle initial, date of birth, primary phone number, and email address. Ensure all details are accurate for effective communication.
3. Continue to provide your street address, city, state, and ZIP code. Include your current or most recent employer and salary information. Reflect on your feelings about preparing a will and select the appropriate options.
4. In Section 2: Family Information, list your spouse’s name and date of birth. Add details for each child including their gender and date of birth. If applicable, provide information about any other legal parents.
5. Move to Section 3: Financial Information. Document both you and your spouse's employment details along with any additional income sources. Clearly indicate your combined annual household income.
6. Section 4 requires a medical provider's input regarding diagnosis information. Ensure this section is completed accurately by the healthcare professional.
7. Finally, complete Section 5: Authorization by signing and dating the form to authorize communication between the Poll Clinic and your medical provider.

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