Program Application (Form 1 of 3)

Date

Email Address where you would like to be contacted about this application

Have you ordered from us before? This application does not need to be filled out more than once. Use the link from your approval email to order supplies.

Client ID (returning mail order participants will be given priority)

first two letters of last name, year you were born, first two letters of where you were born xx/XX/xx

In what general area of Montana are you located?

This program is open to Montana residents ONLY.

Do you identify as American Indian, Indian, Native American, Native?

Geographically do you reside in one of the following areas?

Do you live within (5-10) miles of any of the following syringe service programs:

If you live within (5-10) miles of another syringe service program, tell us about your experience with that program? Be as detailed as possible. There are no right or wrong answers - we want to know what's working and what isn't. Why would you rather order from us? What could your local program do better?

We will share your answers anonymously with that program - our hope is that your honest feedback can help us push for improvements in your community.

How do you describe your CURRENT housing situation?

How does your CURRENT housing status impact your ability to access sterile supplies and/or treatment for HIV/HCV?

How do you usually obtain new supplies? Please be as honest, there are no right or wrong answers. Montana is a big state and you can help us understand what it's really like for drug users in your community.

What happens to your supplies when you are done using them? There are no right or wrong answers, we genuinely want to know. We understand that disposing of syringes 'properly' costs money and can be difficult. The more we know about what your needs really are, the better we can help.

Knowing how people dispose of their syringes can help us learn where disposal box projects are needed! We want to learn how to better support!

This question is about obtaining syringes specifically. Choose all that have applied to you in the past (6) months.

What will these supplies be used with? Select all that apply.

If you were provided with a legitimate and private online source to purchase syringes, would you be willing/able to pay to get sterile syringes by mail?

How often do you reuse or share syringes with others?

HCV (hepatitis C) status?

HIV Status?

Are you under the age of 24? There is no age requirement for our program.

How many sexual partners do you expect to have in the next year?

Do you identify as a sex worker or otherwise trade sex for money or drugs?

Sex Worker rights are a part of the Harm Reduction movement! Check out https://harmreduction.org/issues/sex-work/