top of page

Emergency Housing Intake Form

Please take a moment to fill out the form.

BASIC INFORMATION

How can you be contacted? (check all that apply)

SEXUAL ORIENTATION + GENDER IDENTITY

LANGUAGE, RACE, ETHNICITY

SEXUAL RISK IN THE LAST 12 MONTHS

Have you had vaginal or anal sex in exchange for drugs or money?
Have you had vaginal or anal sex while intoxicated and or high on drugs?
Have you had vaginal or anal sex with a person who has an IDU?
Have you had vaginal or anal sex with a person of unknown HIV status?
Have you had vaginal or anal sex with an anonymous partner?
Have you had vaginal or anal sex without a condom?
Have you had vaginal or anal sex with a person who is HIV positive?
Have you had vaginal or anal sex with a person who exchanges sex for drugs/money?
Have you had vaginal or anal sex with multiple partners?
Have you had vaginal or anal sex with a person who is a known man who has sex with men?

NON-SEXUAL RISK IN THE LAST 12 MONTHS

Have you experienced any of the following risk factors?

Thanks for submitting!

bottom of page