New Horizons Behavioral Health Mobile Unit Request Form
Thank you for your interest in bringing the New Horizons Behavioral Health Mobile Unit to your organization or event! The Mobile Unit provides free, rapid and confidential testing for HIV, Hepatitis C and COVID-19. Trained staff members on board will also provide various resources in relation to both physical and behavioral health concerns. Please complete this brief survey at least 2 weeks in prior to the date/event of which you would like the Mobile Unit to present. *Please note that the Mobile Unit is 38 feet in length and will need legal space to park.*
Requestor Contact Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Company/Organization
Event Information
Name of Event
Date of Event
-
Month
-
Day
Year
Date
Time of Event
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Location of Event
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expected Number of Attendees
Additional Parking/Logistics Information if Available
Event Venue Contact Information if Different
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: