• Sexual Health Interest & Connection Form

    Complete this short, confidential form and our care-navigation team can help you understand your options and connect with appropriate care.

  • 🔒 Confidential | About 2 minutes | No judgment

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    Before You Begin
    This form is for individuals seeking information or connection to care for PrEP, PEP, STI testing or treatment, and hepatitis C testing or treatment. You can choose not to answer questions you are uncomfortable answering.

    Possible HIV exposure within the past 72 hours?

    Do not wait for a response to this form.  Seek medical care as soon as possible and ask about PEP (post-exposure prophylaxis). You may still submit this form, but do not delay urgent care while waiting for our team to respond.

     

  • About You

    Tell us how we can reach you.
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • What is your preferred way for us to contact you?*
  • If we call you is it okay for us to leave you a voicemail?
  • Best time to reach you?*
  • What can we help you with today? (Select any that apply)*

  • PrEP

    A few questions help us understand what information may be useful to you.
  • Are you interested in learning whether PrEP may be right for you?*
  • Are you currently taking medication to prevent HIV (PrEP)?*
  • Have you ever been diagnosed with HIV?*
  • When was your most recent HIV test?*

  • Possible HIV Exposure / PEP

    A few questions help us understand what information may be useful to you.
  • PEP is time-sensitive. If the possible exposure occurred within the past 72 hours, seek medical care as soon as possible. Do not wait for our team to respond to this form.

     

  • When did the possible exposure occur?*

  • STI Testing & Treatment

    A few questions help us understand what information may be useful to you.
  • What can we help you with?*

  • Hepatitis C Testing & Treatment

    A few questions help us understand what information may be useful to you.
  • What can we help you with?*
  • Have you ever been tested for hepatitis C?

  • Insurance & Access

    This helps our team understand possible next steps.

  • Insurance information helps us understand available care and resource options. If a requested service is not available through our program, we may help connect you with an appropriate community resource.

  • Do you currently have health insurance?*
  • What type of insurance do you have?

  • Permission to Connect

    Tell us whether our navigation team may contact you.
  • May a member of our care-navigation team contact you about your request and help connect you with appropriate healthcare services or community resources?*

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    Important Information
    Submitting this form does not establish a provider-patient relationship, does not constitute medical advice, and does not guarantee that any medication, testing, or treatment will be provided. A licensed healthcare provider will determine what care is medically appropriate based on your individual circumstances, testing, and clinical evaluation. When a requested service is not available through our program, our care-navigation team may help connect you with an appropriate community resource.
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