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
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?
Opal
Jeremy
Victor
Christian
Jonnie
Eduardo
Ray
Dani
H.O.T. (House of Trouble)
Open Closet
Gaythering
Grindr
Scruff
Facebook
Instagram
Radio/TV
Website
Google
Friend
Don't know/Don't Remember
Should be Empty: