Program Application (Form 1 of 3)

Date

MonthDayYear
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.*

YesNo
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.

I am requesting supplies be mailed to me in MontanaI do not live in Montana and I understand my application will be denied.
Do you identify as American Indian, Indian, Native American, Native?*

YesNo
Geographically do you reside in one of the following areas?

Flathead Reservation (Pablo)Blackfeet Reservation (Browning)Rocky Boy’s Reservation (Rocky Boy Agency)Fort Belknap Reservation (Ft. Belknap)Fort Peck Reservation (Poplar)Northern Cheyenne Reservation (Lame Deer)Crow Reservation (Crow Agency)Little Shell Chippewa Tribal Capital (landless, but headquartered in Cascade County) – Little Shell Band of ChippewaNo, I do not.
Do you live within (5-10) miles of any of the following syringe service programs:*

Open Aid Alliance ~ Polson - 802 Main St, Polson, MT 59860Flathead Family Planning (3rd Floor) - 1035 1st Ave West Kalispell, MT 59901Butte Family Planning Clinic (inside Butte Silver Bow County Health Department) - 25 W Front St. Butte, MT 59701Riverstone Health - 123 South 27th Street Billings, Montana 59101(I do not live near any syringe service program.)
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.*

I do not feel safe purchasing syringes from my pharmacy.I have received syringes by mail from Open Aid Alliance in the past six months.My town does not have a pharmacy.I could not afford to purchase new syringes.I could not travel to purchase new syringes.I have been given new, sterile syringes by others for freeI have purchased syringes online successfully.I have tried to purchase syringes online unsuccessfully.I do not care what syringes I use or how I get them.I have smoked, snorted, or swallowed drugs because I did not have sterile syringes.Other
What will these supplies be used with? Select all that apply.*

Opiates (not including fentanyl)MethCocaineCrackKetamineBenzos (Xanax, Valium, Klonopin, etc.)"Blues" or other counterfeit pressed pillsPrescription Pills (yours or someone else's)Suboxone or SubutexFentanylHeroinMethadone (injected)Suboxone or Subutex (injected)Other
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?*

HCV+HCV+ but no viral loadHCV+ and interested in treatmentUnsure / not tested recentlyI do not wish to disclose
HIV Status?*

HIV+ and receiving treatment or servicesHIV+ and not involved with treatment or servicesUnknown / not tested recentlyI do not wish to disclose
Are you under the age of 24? There is no age requirement for our program.*

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

NoneOneSeveralMany
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/
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