Request Services
Please fill out the form below. The information you provide will assist us in providing you with the best care.
Legal Name
*
First Name
Last Name
Personal Name
First Name
Last Name
Pronouns
*
Please Select
She, Her, Herself
He, Him, Himself
They, Them, Themselves
Ze, Zir, Zirself
Other
Gender Identity
*
Please Select
Woman
Man
Trans Woman (MtF)
Trans Man (FtM)
Non-Binary
Intersex
Other
Date of Birth
*
-
Month
-
Day
Year
Please note: EDGE NJ provides care to individuals who are 13 years or older.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Please Select
Morris
Sussex
Warren
Union
Essex
Other
Email
*
Phone Number
*
Best Mode of Contact
*
Please Select
Phone
Email
Both
What are the best days/times for us to contact you?
Eligibility Demographics
*
I identify as part of the LGBTQ+ community.
I am a parent/guardian of an LGBTQ+ child.
I am a person living with HIV.
I have an increased likelihood of contracting HIV. (HIV+ Partner, Condomless Sex, IV Needle Use, etc.)
I choose not to disclose at this time.
Which services are you interested in? Check all that apply to you.
*
HIV Care Coordination (Provider, Insurance and Pharmacy Assistance, Social Services, etc)
LGBTQ+ Care Coordination (Gender Affirming Care, Legal Name Change and Social Services, etc.)
HIV/STI Testing and Prevention (Rapid Testing, Referrals, PrEP Navigation, Free Condoms, etc.)
Harm Reduction (Drug User Health Support, Overdose Prevention, Syringe Access, Safer Substance Use Supplies, etc.)
Residential Services (Shelter, Housing, Utilities)
Behavioral Health Care (Outpatient Individual Counseling)
Support Groups
Please select the following reasons for seeking counseling:
*
Adjustment Disorders/Coping with change
Anxiety/Stress
Depression
Gender Affirming Letter of Support
Gender Dysphoria
Grief and Loss
Mood Disorders (i.e. Bipolar Disorder)
Neurodiversity (i.e. Autism, ADHD)
Personality Disorders
Substance Use Disorders/Recovery
Trauma
Other
Primary Insurance Coverage
*
Please Select
NJ Medicare
NJ Medicaid
Aetna
Horizon NJ Family Care
United Health Care
Other
Uninsured
Cost should never be a barrier to care. We accept most insurances. We also maintain various grants for underinsured and uninsured people.
Additional information
EDGE NJ may take up to 5 business days to review online form submissions. We will contact you via your preferred method of communication as soon as possible. This form should not be used for immediate crisis needs. If you are having a mental health emergency, please call 911 or 988.
*
Click here to acknowledge that you have read and understand the above statement.
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