Request Services

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 NameLast Name
Personal Name

First NameLast Name
Pronouns*
Gender Identity*
Date of Birth*

MonthDayYear
Please note: EDGE NJ provides care to individuals who are 13 years or older.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Email*
Phone Number*
Format: (000) 000-0000.
Best Mode of Contact*
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 note: The following services are currently at capacity. By completing this form you will be contacted for consideration for the waitlist.
- LGBTQ+ Care Coordination: 6-9 months
- Residential Services: 1-2 years
- Behavioral Health Care: 3-6 months
Please select the following reasons for seeking counseling:*

Adjustment Disorders/Coping with changeAnxiety/StressDepressionGender Affirming Letter of SupportGender DysphoriaGrief and LossMood Disorders (i.e. Bipolar Disorder)Neurodiversity (i.e. Autism, ADHD)Personality DisordersSubstance Use Disorders/RecoveryTraumaOther
Primary Insurance Coverage*
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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