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HIV Online Questionnaire Form
1
Do You Have HIV?
*
This field is required.
Yes
No
Not Sure
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2
Are you interested in scheduling an appointment for a FREE & confidential HIV Test or an At Home HIV Test?
Yes
Not Right Now
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3
What category of services are you interested in? You CAN select multiple
Detailed description on webpage
HIV CARE SERVICES FOR PEOPLE LIVING WITH HIV
HIV PREVENTION SERVICES
WRAP AROUND CARE SERVICES FOR PEOPLE LIVING WITH HIV
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4
HIV CARE SERVICES FOR PEOPLE LIVING WITH HIV
Please select ALL of the services you are interested in
HIV Medical Care
Home Health Care
Case Management
Mental Health Counseling
Early Intervention
Linkage to Care
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5
FREE HIV PREVENTION SERVICES
Please select ALL of the services you are interested in
Confidential HIV Testing
Safer Sex Counseling
FREE Condoms & Lube
PrEP + PEP Services
At Home HIV Test Kits
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6
WRAP AROUND CARE SERVICES FOR PEOPLE LIVING WITH HIV
Please select ALL of the services you are interested in
Co-Payment & Deductible Assistance
Tobacco Reduction Support
Dental Health Care
Housing Assistance
Hygiene Products
Food & Clothing
Transportation
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7
What is the best method to contact you?
*
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Select all that apply
Phone
Email
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8
Phone Number
Please enter a valid phone number.
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9
Email
example@example.com
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