Case Management Intake
Case Management is a client-focused process used to help people navigate life challenges by making goals together and connecting them with the right support and resources to meet those goals. If you would rather complete this in person please give us a call at 901-278-6422.
Program Information
PRYSM Care Navigation is our program for LGBTQ+ Youth 12-17 & their families.TREAT is our Case Management Program for community members living with HIV. Metamorphosis is our Case Management Program for LGBTQ+ youth ages 18-24.
What Case Management program are you interested in?
Please Select
PRYSM Care Navigation (Parent/Guardian Form)
PRYSM Care Navigation (Youth Form)
Metamorphosis (18-24)
Positive Health Case Management (HIV+)
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Needs Assessment
How did you hear about us?
Please Select
Online Search
Social Media
Friend/Family Member
Other organization
Other
What services are you seeking from OUTMemphis?
Food
Clothing
Transportation
Mental Healthcare
Hygiene Supplies
HIV Testing
Sexual Health Services
Life Skills
Social Support Groups
What other services do you need that we can connect you with?
Housing
Medical
Dental
Immigration Law Referral
Employment
Gender affirming care
Other
How would you describe your current housing situation?
Literally Homeless (sleeping outside, in a car, or someplace else not meant for sleeping)
Imminent Risk of Homelessness (currently housed but have an eviction notice or a letter stating you must move and otherwise have nowhere else to go)
Fleeing or Attempting to Flee Domestic Violence (currently housed but with someone that is harming you and you have nowhere else to go)
Other
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Documents
Please bring documents that you have to your first Case Management meeting or upload below. You do not have to have all of your documents to be in a program.
Do you have your:
Social Security Card
Birth Certificate
ID
Ryan White Card (if applicable)
First page of lease (if needing housing services)
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Contact Information
Preferred Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Primary Caregiver's Email
example@example.com
Do we have permission to:
Call
Text
Email
Zipcode
Please enter N/A if no permanent address
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Demographic Information
What is your gender? (select all that apply)
Agender
Genderqueer
Man
Non-Binary
Woman
Transgender
Two-spirit
Do not know/questioning
Prefer not to say
Other
What are your pronouns?
When is your birthday?
-
Month
-
Day
Year
Date
What is your marital status?
Please Select
Single
Married
Divorced
Separated
Widowed
What is your sexual orientation?
Please Select
Asexual
Bisexual
Demisexual
Fluid
Gay
Greysexual
Lesbian
Pansexual
Queer
Questioning or unsure
Straight/heterosexual
Prefer not to say
additional category/identity not listed (please specify below)
What is your race and ethnicity?
American Indian, Alaska Native, or Indigenous
Asian or Asian American
Black, African American, or African
Hispanic/Latina/e/o
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Other
What is your primary language?
What is your source of income?
Please write N/A if needed
Are you a veteran?
Yes
No
Do you have insurance?
Yes
No
What kind of insurance do you have?
Do you have access to the internet regularly?
Yes
No
Do you have access to reliable transportation?
Yes
No
Do you have access to regular meals (at least two a day)?
Yes
No
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PRYSM Care Navigation (Parent/Guardian Form)
For parents of LGBTQ+ 12-17 year olds seeking social support, mental health support, and/or gender affirming healthcare
What youth are you responsible for?
Who lives in your house?
Do you have supportive community?
Yes
No
Are you seeking gender affirming healthcare for your youth?
Yes
No
Thank you for completing the intake form! Next, a case manager will review your information and meet with you to make some goals. Please pick a time below that works for you!
*
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PRYSM Care Navigation (Youth Form)
For LGBTQ+ 12-17 year olds seeking social support, mental health support, and/or gender affirming healthcare
What is your caregiver(s) marital status?
Please Select
Married
Divorced
Separated
Widowed
Who do you live with?
Are you currently attending school or another educational program (e.g., homeschool), either part-time or full-time?
Yes
No
Where?
Have you ever relocated schools due to your identity?
Yes
No
Do you feel affirmed at school?
Yes
No
Do you feel safe at school? (Free of physical harm/threats, free from harassment/bullying)
Yes
No
Do you have an adult who makes you feel safe at school?
Yes
No
Who?
Are you seeking gender affirming healthcare?
Yes
No
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Metamorphosis
For LGBTQ+ 18-24 year olds seeking housing stability
Education/Employment
Do you need training or vocational support to achieve employment in your desired occupation?
Yes
No
Are you currently participating in any vocational support to achieve employment in your desired occupation?
Yes
No
Are you currently enrolled in school or another educational program (e.g., GED), either part-time or full-time?
Yes
No
Housing/Independent Living
Do you currently receive any housing subsidies? (ex: section 8, low income housing, etc)
Yes
No
Do you or have you ever paid your own rent?
Yes
No
Do you or have you ever paid your own utilities?
Yes
No
Do you have any outstanding debts (Past due MLGW bills, evictions, etc.)? Please describe type of debt and amount (s):
Legal Considerations
*Please note that this does not affect your eligibility for any OUTMemphis services. This information is only used to assess for legal assistance referrals and is optional.*
Do you have any current legal issues?
Yes
No
Are you currently on probation/parole?
Yes
No
Do you have any prior arrests, convictions or incarcerations?
Yes
No
Do you have car insurance (if applicable)?
Yes
No
Does not apply
Thank you for completing the intake form! Next, a case manager will review your information and meet with you to make some goals. Please pick a time below that works for you!
*
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Positive Health Case Management
For our community members living with HIV
Thank you for completing the intake form! Next, a case manager will review your information and meet with you to make some goals. Please pick a time below that works for you!
*
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Emergency Contact & Disclosures
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to You:
Confidentiality & Consent for Services
Confidentiality Agreement: I understand that the information provided will be kept confidential and only shared with relevant organizations for the purpose of delivering services with the exception of harm to self or others.
I agree
I do not agree
Consent for Services: I consent to participate in the programs and services provided by OUTMemphis, and I understand that the staff will assist me in accessing the appropriate resources based on my needs.
I agree
I do not agree
Anything else we should know?
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Thank you for reaching out!
Thank you for your interest in our Case Management program. At this time, our case management services for 18–24-year-olds are specifically focused on supporting young adults experiencing homelessness. Because your situation does not meet those criteria, we’re not able to offer case management services. However, you are absolutely welcome to continue accessing the Youth Empowerment Center. You can come by to spend time, connect with staff, and make use of our support services—including laundry, programming, and food assistance. We’re glad to have you as part of our community, and we’re here to support you in the ways we can.
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