HIV Self-Test Kit Request Form
Self-Test Kit Questionnaire
We know that some of the questions here may not be phrased in a way that is affirming to the entirety of our community. Unfortunately, our funders require that we ask these questions. Thank you for your understanding.
Name
*
First Name (Legal name not required)
Last Name (Legal name not required)
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the best method for us to reach you?
Phone Call
Text Message
Email
I don't have reliable phone or internet access
How would you like to receive your test kit?
We can discreetly mail the kit to you or you can pick up the kit at either of our locations during opening hours. If you choose to pick up the kit, please text us at 347-943-4227 or email us at resources@lgbtbrooklyn.org to schedule a pickup time.
I would like to:
Have the test kit mailed to me
Pick-up the test kit at the Center's Crown Heights location (1561 Bedford Ave)
Pick-up the test kit at the Center's Bed-Stuy location (1360 Fulton St)
Another event:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip Code
*
5 digit zip code
Back
Next
What are your pronouns? (select all that apply)
*
She/Her
He/Him
They/Them
No pronouns - use only my name
Other
What is your ethnicity?
*
Hispanic or Latine
Not Hispanic or Latine
Don't Know
Declined
What is your race?
*
Native American/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Don't Know
Declined
What is your race?
Native American/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Don't Know
Declined
What sex were you assigned at birth?
*
Male
Female
Intersex
Declined
Which term most closely matches how you would describe your gender?
*
Cisgender Woman
Transgender Woman
Cisgender Man
Transgender Man
Non-Binary
None of the above genders fit me, but I do identify as part of the trans community
None of the above genders fit me, but I don’t identify as part of the trans community
Declined
Back
Next
In the past 5 years, have you had sex with a cisgender man?
*
Yes
No
Declined
In the past 5 years, have you had sex with a cisgender woman?
*
Yes
No
Declined
In the past 5 years have you had sex with a transgender person? (this includes trans folks of any gender)
*
Yes
No
Declined
In the past 5 years, have you shared any needles or other injection equipment with other individuals?
*
Yes
No
Declined
Have you ever heard of PrEP (Pre-Exposure Prophylaxis), a medication used to prevent HIV?
*
Yes
No
Declined
Are you currently taking PrEP?
*
Yes, daily in pill form (Descovy or Truvada)
Yes, bi-monthly injection (Apretude)
No, I am not currently taking PrEP
Have you used PrEP anytime in the last 12 months?
*
Yes
No
Declined
Have you ever been tested for HIV?
*
Yes
No
Don't Know
Declined
How did you find our HIV home test kit program?
Email from Brooklyn Community Pride Center
Social media (e.g. Instagram, Facebook, LinkedIn)
Dating apps outreach (e.g. Lex, Grindr, Sniffies)
Brooklyn GHOST Project/Kickback Wednesdays
An event at Brooklyn Community Pride Center
An external event not at Brooklyn Community Pride Center
A partner, friend, coworker, or acquiantance
Other
Back
Next
Would you like any information on the following support services?
Additional sexual health services
Health insurance navigation
Mental health services
Food assistance
Housing navigation
Support groups
Community events
I am not interested in any other services
I would like to request the following safer sex supplies, if in stock:
I would like a mix of various products
Standard condoms
XL condoms
Non-latex condoms
Dental dams
Internal condoms
Flavored condoms
Studded condoms
Ribbed condoms
Lube
Extra strong condoms
Finger cots
None
I would like to request a harm reduction kit, including fentanyl test strips, if in stock:
Yes
No
If you would like to request a pair of Thinx underwear (used for periods, bladder leaks, etc) and would not otherwise be able to purchase a pair, please enter your size below (XS-4X). If you need a particular style/cut (e.g. boyshorts, brief), please indicate that as well.
Submit
Should be Empty: