Be.

Be.

Self-Testing made easier for you, in the comfort of your own space! We Got You!
STI Self-Screening Kit Form

Fill this form out to receive a free self-screening kit which can screen for: HIV (I & II) A team member can discuss options if you want to get any other STI screening. A team member from The T.R.U.T.H. Project will contact you through text message, or your preferred contact method, within 24-48 hours, Monday- Saturday.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Verify Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Race*
Hispanic/LatinX Orgin?*

YesNo
Date of Birth*

MonthDayYear
Email*
example@example.com
What is your preferred method of contact?*
We will contact you by your preferred method for but not limited to the following: Send Tracking Number. Provide PrEP Resources. Provide Linkage Resources.

What is your gender identity?*
How do you identify?
What is your sexual orientation?*
Who do you have sex with?
How did you hear about this self-screening program?*
Are you a person living with HIV?*

YesNoStatus Unknown
How often do you get tested?*
Are you familiar with PrEP?*
Do you have insurance?*
CONSENT: I consent to receiving contact from The T.R.U.T.H. Project staff through my preferred contact method to provide information about potential resources, treatment options, and results. I also consent to The T.R.U.T.H. Project, to order and ship my self testing kit to the shipping address above. Our team respects your privacy, and will always attempt to use the utmost discretion in our communications with you.*

I agree to the privacy policy.No I do not agree to the privacy policy.
Please Confirm and verify that all your entered information is correct.*

Yes, my entered information is correct.
Please verify that you are human*
Should be Empty:

STI Self-Screening Kit Form