Support Services Request

Today's Date

Date of Birth: *

Date

Age

Is it Ok to contact you? *

Yes No

Preferred Name: (How do you want to be addressed?) *

First Name Last Name

Legal Name: (For medical purposes only! We will not address you by this name.) *

First Name Last Name

Pronouns *

She/ Her He/Him They/them Zi/Zir Other

Social Security Number (enter n/a if it does not apply to you) *

NOTE: Only required for clients in need of medical services

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Email

example@example.com

How do you identify? *

Man/Male (Not Trans) Woman/Female (Not Trans) Trans/Non Binary/GNC I prefer not to say/ Im not sure Trans Femmine Trans Masculine Do not wish to disclose Other

What is your sexual orientation? *

Straight (Cis) Straight (Trans) Same Gender Loving Bi/Pan Sexual Do not wish to disclose Other

What is your Race/Ethnicity? *

African American Caucasian Latin(x) Do not wish to disclose Other

Do you have stable and affirming housing?( Note: For us, affirming housing supports your life choices regardless of Sexual Orientation or Gender Identity)

Yes I have both Yes it is stable but not always affirming No I don't have stable housing, but the people I stay with affirm me. I do not have a TGNC/LBGQ affirming household I am experiencing houseless/homeless Other

Do you know your HIV status?

Yes, my status is Non Reactive (Negative) Yes, my status is Preliminary Reactive (Non Confirmatory) Yes, my status is Reactive (Confirmatory) No, I do not know my status. No, This is my first HIV test.

Do you want to be a member also or is this registration for STD/STI Testing only? *

Testing & Membership Enrollment I am requesting testing only.

Cash app (If doing STD/STI Testing):

For example $TKOBLACKSHEEP

	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

	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

	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.

	Select	How soon are you looking to be linked to care?
Hormone Therapy (HRT)
Primary Care Physician
STD/STI Testing/Treatment
OB/GYN
None/Not Applicable

FAITH Enrollment/Testing Form

Client Demographic Information

Initial Needs Assessment/Support Services

Are you considered high risk?