Prevention 305 Client Intake Form

1
Name* This field is required.Nombre
First Name (Primer Nombre)
Last Name (Apellido)
2
Email* This field is required.Correo electrónico
example@example.com
3
Phone Number* This field is required.Número de teléfono
Please enter a valid phone number.
4
Gender Identity* This field is required.Identidad de Género
Male
Female
Trans Male
Trans Female
Non-binary
Agender
Genderqueer
Genderfluid
Questioning or unsure
Other
Prefer not to disclose
5
Sexual Orientation* This field is required.Orientación Sexual
Gay
Straight (Heterosexual)
Lesbian
Bisexual
Pansexual
Queer
Questioning or Unsure
Other
Prefer not to answer
6
Date of Birth* This field is required.Fecha de nacimiento
Date
Month
Day
Year
7
Race* This field is required.Raza
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unsure
8
Ethnicity* This field is required.Etnicidad
Hispanic or Latino
Not Hispanic or Latino
Other
Unsure
9
Country of Birth* This field is required.País de Nacimiento
10
Current Zip Code* This field is required.Código Postal Actual
11
CountyCondado Actual
12
Which service are you seeking?En qué servicio estás interesado?
PrEP/PEP
HIV/STI Testing
Condoms/Other
Unsure
13
Do you have Medical Insurance?* This field is required.¿Tienes Seguro Médico?
YESNO
14
Do you need Transportation?* This field is required.¿Necesitas transporte?
YESNO
15
Do you have a Disability? * This field is required.¿Tienes alguna discapacidad?
No
Physical
Visual
Hearing
Unsure
Prefer not to disclose
16
How did you find us?* This field is required.¿Cómo te enteraste de nosotros?
Gramps
Villain Theater
Opal
Jeremy
Thaydee
Victor
Eduardo
Ray
Daniel Jimenez
House of Trouble
Ashlyn Pia
Enrique Salas
Franklin Salomon
Gabriela Vergara
Grindr Ad
Facebook
Instagram
Google
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