PrEP Referral

Get Help Finding, Starting, or Staying on PrEP!

Please provide the following basic information and a member of our team will reach out with next steps to connect you to PrEP care in Arkansas.
First and Last Name*

First NameLast Name
Preferred Language*

EnglishSpanish
Gender*

FemaleMaleTransgenderOther
Phone Number*

Area CodePhone Number
Are you able to receive text messages at this phone number?*

YesNo
E-mail*
Please provide your address to help us understand what area of the state you live in. When we receive your request, we will do our best to connect you to a community partner offering PrEP services in your local community.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long has it been since your last HIV test?*

Less than 1 month2-6 months7-12 monthsMore than 12 monthsI have never been tested
Which best describes your knowledge or use of PrEP (Pre-Exposure Prophylaxis?*

I do not know about PrEP.I have taken PrEP sometimes.I have taken on-demand PrEP around sexual activity.I have heard of PrEP, but never taken it.I used to take PrEP once a day as prescribed.I was taking PrEP, but am not now.Other
How did you learn about PrEPared for Life?*

Brochure or Printed MaterialDating App (Grindr, Scruff, Tindr)Facebook or InstagramGoogle or Online SearchPodcastReferred by friendReferred by staff at EACSpecial EventWebsite - Arkansas Resource HubWebsite - Engaging Arkansas CommunitiesOther
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Get Help Finding, Starting, or Staying on PrEP!