ManDate Intake Form

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? *

Current age *

Home address

Address Line 1

Address Line 2

City

State

Zip Code

Is your mailing address the same? *

Yes
No

Preferred language *

English
Spanish
Other

Ethnicity *

Hispanic
Not Hispanic
Don't know

What pronouns do you prefer?

Pronouns are things like he/him, she/her, they/their, mx, ze or others as you'd prefer

Education level *

Some high school
Finished High School/GED
Some college, no degree
Degree

Do you have insurance? *

Yes
No

Household size: (Please include members of your permanent household only) *

Are you interested in notifications from us regarding future events, and/or other important information? *

Yes
No

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+

Have you had an HIV test in the last 12 months? *

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

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?

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?

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