Support Services Request

	Select
Utility Assistance
Norco Harm Reduction (Overdose Prevention) Kit
Care Packages (deodorant, toothpaste, personal hygiene items, etc.)
Safe Sex Kits (Condoms/Lubricant/education)
Pregnancy Test/Plan B (Day After Pill)
Food Bags/Household Supplies
Counseling/ Mental Health
Housing Stipend

	Select
Counseling/ Support Groups
Name/Gender Marker Amendment (Domestic)
Name/Gender Marker Amendment (Regional)
ID Docs Amendment/Replacement
81 mg Aspirin/Vitamin D, supplements etc.
Medicine Kits (Sharps container, alcohol pads, cotton balls, & band-aids)
Mederma/Scar Cream
Razors/Shaving Cream
Body balm/cream
Hygiene products (deodorant, toothpaste, douche, sanitary pad, etc.)
Cellphone
Food Support


Hormone Therapy (HRT)
Primary Care Physician
STD/STI Testing/Treatment
OB/GYN
None/Not Applicable

Where are you getting tested: (at-home, Dallas, Montgomery, Jefferson, Houston or Mobile County)*

Have you ever heard of PrEP (PRE-EXPOSURE PROPHYLAXIS)*

YesNo

Are you currently taking PrEP medication?*

YesNoNo but I am interested in learning more about receiving PrEP for free.

Have you taken PrEP medication in the last 12 months?*

YesNo

Select all that apply: In the past 12 months have you had sex with a..*

Sex with multiple partners (within the last 90 days)Sex with a person who injects drug substances (prescribed or unprescribed)Sex without protection (at least once without condom)Sex with someone of the same gender (MSM only)Sex with someone who identifies as TransgenderSex with a person who does sex workI am a sex worker.

Have you had any flu like symptoms (fever, sore throat, chills etc.) within the last 90 days?*

YesNo

Would you like to get tested for any additional STI/STD other than HIV?*

Do you have a primary care physician?*

YesNo

Do you have health insurance?*

YesNo

What's your insurance card number? If none type "none"*

List any prescriptions/medications you need covered:

Ex: Losartin Allergy Pill 10 mg

Pictures of prescription you are currently prescribed

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Please make sure the name and contact information of the pharmacy, your prescription name and dosage is readable.

Signature: By Signing this form you agree that the information you have provided is true to the best of your knowledge.*

Clear

YOU MADE IT!

Thanks for taking the time to submit this needs assessment for us. These assessments help us figue out which services and resources the community values and helps us better provide the resources our community wants.

	Select	Size
Padded Bra
Underwear/Panties
Breast pads, Body Shapers, etc.
Makeup/ Facials/Cosmetics
Lashes/Wigs
Perfume/Body Spray
None

	Select	Size
Underwear/Boxers
Binder/Suppression Suit
Packers/Stp
Shoe lifts (height enhancement)
Minoxidil/beard balm/oil
Cologne/Fragrance
None
Brush, durag, shaving, etc.

FAITH Enrollment/Testing Form

Client Demographic Information

Initial Needs Assessment/Support Services

Are you considered high risk?