Are you currently experiencing homelessness? ((( drop down y/n )))

How many people are in your household? (((text box)))

What is your total monthly income for your household? (((text box)))

What state do you live in? ((( drop down state list )))

Do you have Medicaid?  ((( drop down y/n )))

Do you have Health Insurance?  ((( drop down y/n)))

(if yes) does it cover Abortion?  ((( drop down y/n)))

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