Support Services Request

Reproductive Justice Needs Assessment

A Collabrative Community Initiative by TKO Society & Yellow Hammer Fund
Notice: Due to limited funding we prioritize our support services to Black Alabamians who identify as TGNC and LGBQ . We will accept requests from surrounding southern states (TN,GA,MS,FL) on a case by case situation.

For more information about The Knights & Orchids Society or Yellow Hammer Fund, please visit our website (www.tkosociety.com) or social media pages.
Demographic Information
Today's Date *

Month Day Year
Ok to contact *

Yes No
Preferred Name: (How do you want to be addressed?) *

First Name Last Name
Pronoun *

She/ Her He/Him They/them Zi/Zir
Date of Birth: *

Month Day Year
Date
How do you identify? *

Cisgender Woman Cisgender Man Trans Feminine Trans/Non Binary/GNC Trans Masculine I prefer not to say/ Im not sure
What is your sexual orientation?

Straight Same Gender Loving Bi-Sexual Do not wish to disclose
What is your Race/Ethnicity?

African American Caucasian Latin(x) Do not wish to disclose
Age
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Location
I would like to receive a HIV/STD health screening. *

Yes, Please. No thank you.
I would like to receive a special care package while supplies last. (TGNC Folks only) *

Yes, Please. No thank you.
Have you ever heard of PrEP (PRE-EXPOSURE PROPHYLAXIS) *

Yes No
Are you currently taking PrEP medication? *

Yes No No but I am interested in learning more about free PrEP
Have you taken PrEP medication in the last 12 months? *

Yes No
Select all that apply: In the past five years have you had sex with a.. *

Man Woman Transgender Person Person who inject drug substances (prescribed or unprescribed)
Would you like more information about additional services offered?

Yes, Please. No thank you.
SUPPORT SERVICES REQUEST
2. How many Military Veterans?

How many of each age group is in the household?

Satisfied

0-12

13-18

19-29

30-39

40-49

50-59

60-69

70 and up

Please check one or more boxes below:

My household receives food stamps. My household receives SSI. My household has special circumstance. (Fire, Flood, Homeless etc.) My household is below poverty level. (unemployed, low-income, etc.) I am not safe/experiencing violence/domestic violence. None of these apply to my household.
Are you currently employed?

Yes No

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 things our community wants. Feel free to go back through and check your answers or you can hit submit now.
Should be Empty:

Reproductive Justice Needs Assessment

Demographic Information

SUPPORT SERVICES REQUEST

Essential Support Services