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LGBT Life Center
Empowering the LGBTQ and HIV communities since 1989.
Call Us
(757) 640-0929
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info@lgbtlifecenter.org
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ManDate Intake Form
ManDate Intake Form
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Contact information
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Step
1
of 6
Legal name
*
First
Last
Preferred name
*
First
Last
Phone number
*
Phone type
*
Cell
Landline
Today's date
*
Email
*
Preferred way of being contacted
*
Phone
Text
Email
What is your birth date?
*
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Current age
*
Home address
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Is your mailing address the same?
*
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Mailing address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
Florida
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Iowa
Kansas
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Ohio
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Pennsylvania
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South Dakota
Tennessee
Texas
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Washington
West Virginia
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State
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Preferred language
*
English
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You selected "other" as your preferred language. Please tell us which language you prefer:
Will will do our best to communicate in your preferred language whenever possible.
Next
Ethnicity
*
Hispanic
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Hispanic - subgroup
*
Puerto Rican
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Mexican/Mexican, American/Chicano/a
Other origin
Race
*
Am. Ind/AK Native
Black/African Am.
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Asian
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Asian - subgroup
*
Asian Indian
Chinese
Japanese
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Native Hawaiian/Pac. Islander – subgroup
*
Native Hawaiian
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Samoan
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Current gender identity
*
Male
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Trans male
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Gender non-conforming/Non–binary
Prefer not to say
Other
You selected "other" for current gender identity, would you like to specify?
If you would not like to specify, skip this question
What pronouns do you prefer?
Pronouns are things like he/him, she/her, they/their, mx, ze or others as you'd prefer
Sexual Orientation (check only one please)
*
Gay
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You selected "other" for sexual orientation, would you like to explain further?
This question is optional
Marital status
*
Married
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Education level
*
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Do you have insurance?
*
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You said you do not have health insurance. Would you like assistance in applying for insurance?
*
Yes
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Type of Insurance:
*
Private – Employer
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VA, Tricare or Military Health Care
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Household income: Please identify your annual household income using the check boxes provided
*
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$1-$10,000
$10,001- $20,000
$20,001- $30,000
$30,001-$40,0000
$40,001-$50,000
$50,001- $60,000
$60,000+
Household size: (Please include members of your permanent household only)
*
How did you hear about LGBT Life Center and our services (check all that apply):
Word of mouth
Online/Social media
Billboards/Public transit
Presentation/Employee
Referral
Other
You selected "online/social media" for how you heard about us. Can you tell use which service you heard about us on?
*
Facebook
Twitter
Instagram
Jack'd
Scruff
Grindr
LinkedIn
Google search
Another website
You selected "billboards/public transit" for how you heard about us. Can you tell us where?
*
Hampton roads transit
Bus/transit stop
Billboard ad
Other
You selected "presentation/employee," do you remember the employees's name or where the presentation was?
Are you interested in notifications from us regarding future events, and/or other important information?
*
Yes
No
How do you prefer to receive this information?
*
Email
Mail
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How did you hear about ManDate?
*
Facebook
Instagram
Twitter
Jack'd
Grindr
Scruff
Our website: lgbtlifecenter.org
Staff at LGBT Life Center
HIV/STD testing at LGBT Life Center
Program at LGBT Life Center
Which staff member did you hear about ManDate from?
Leave blank if you did not select "Staff at LGBT Life Center"
Which program did you hear about ManDate from?
Leave blank if you did not select "From at program at LGBT Life Center"
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Vaginal or anal sex with a male…
without using a condom
who injects drugs
who is HIV+
Vaginal or anal sex with a female…
without using a condom
who injects drugs
who is HIV+
Vaginal or anal sex with a transgender person…
without using a condom
who injects drugs
who is HIV+
I have...
used injection drugs
shared drug injection equipment
exchanged sex for drug/ money/something else you need
condomless sex for drug/ money/something else you need
sex while intoxicated and/or high on drugs
sex with a person whose HIV status is unknown
sex with a person who exchanges sex for drug/money/etc.
sex with anonymous partner
sex with multiple partners
condomless sex with multiple partners
oral sex
diagnosed with a sexually transmitted disease
Previous
Next
Have you had an HIV test in the last 12 months?
*
Yes
No
If yes, what were the results?
negative
positive
What was the date of your test?
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28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1926
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1924
1923
1922
1921
1920
Are you linked to medical care?
*
Yes
No
Have you attended an HIV medical appointment in the last 6 months
*
Yes
No
Are you currently prescribed HIV meds?
*
Yes
No
Are you taking your HIV meds daily?
*
Yes
No
If you would like to speak with a staff person about any of our services or questions in this survey, please initial here
Previous
Next
Your health and well-being are important to us. Please take a few minutes to complete this questionnaire so that we can offer assistance in finding the resources you may need.
What health concern would you like help with today?
Which of these services do you need help with?
STD testings
HIV testing
Hepatitis B & C testing
Housing
Food
Job training
Employment
Clothing
GED or other education
Transportation
Health insurance
PrEP
nPEP
HIV treatment/medication
Addiction or recovery services
Mental health services
Domestic / Partner violence
I'm not sure
None of these
Other
Please check all that apply
You select "other," would you like to tell us more?
Please respond "Yes" or "No" to the questions below. Your answers will help us know more about you and how we may be able to help you with your health.
Do you have trouble getting to health appointments, your job or other important places?
*
Yes
No
Are you concerned about losing your current housing, or have you lost your housing?
*
Yes
No
In the last 3 months, have you had any “turn-off” notices, disconnections, or eviction notices?
*
Yes
No
Do you have health insurance?
*
Yes
No
Do you feel safe in your home or where you sleep at?
*
Yes
No
Do you feel safe in your relationships?
*
Yes
No
Have you been sad, depressed, anxious or nervous most of the time in the past 30 days?
*
Yes
No
In the past 30 days, did you consume 4 (for females) or 5 (for males) alcoholic drinks in one sitting?
*
Yes
No
In the past 6 months, have you used drugs other than those required for medical reasons?
*
Yes
No
Is there anything else you would like us to know?
Message
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