Free STI tests and Safer Sex Kits Intake form

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Thank you for taking control of your health! This information is required for everyone seeking free STI testing (HIV, gonorrhea, and chlamydia) and safer sex kit deliveries. All information is kept confidential. Due to the disproportionate impact of HIV transmission to specific communities, our free, risk-based STI testing services and safer sex kit deliveries are specifically for LGBTQIA+ men, same gender loving men, men who do not identify as LGBTQIA+ and have sex with men, and trans+ women.

Full Name *

First Initial of mother's first name (this is to create client codes on our data entry system) *

Email *

Phone number *

Address *

County of residence & Zip Code *

Country of Origin *

Date of birth *

YYYY

Sex at Birth *

Male

Female

Intersex

Prefer not to say

Other:

Current Gender *

Male

Female

Intersex

Trans man

Trans woman

Nonbinary/gender nonconforming

prefer not to say

Other:

Required

Sexual Orientiation *

LGBTQIA+

Heterosexual

Questioning/Curious

Queer

Other:

Required

Ethnicity: Check all that apply *

Hispanic or Latinx

African American/African Diaspora

American

Asian

Native American/Indigenous

Native Hawaiian

Pacific Islander

Caucasian

Decline

Other:

Required

Housing Status in the Past 12 Months *

Literally homeless

Unstably housed or at-risk of losing housing

Stably housed

Decline

Don’t know

Health Insurance Status *

Currently Insured

Applied for Insurance

Uninsured

Don't know

Primary Medical Care Status *

Has a primary medical care provider relationship

Seeks emergency care as needed where available

No medical visits in the past 2 years

Have you ever had an HIV test? *

Yes

Maybe

Other:

Previous HIV test (if this is your first time, put your date of birth) - this can be an estimated date *

YYYY

Previous HIV test result *

Preliminary positive

Confirmatory positive

Negative

Invalid

Unknown

Other:

Would you like a free rapid HIV test? *

Yes

Maybe

Would you like a free gonorrhea and chlamydia test? *

Yes

Maybe

Location of preference *

Flexible time slots every day of the week: Kenneth Young LGBTQ Center located at 650 E Algonquin RD Schaumburg, IL 60173 (HIV, gonorrhea and chlamydia)

Tuesdays 4:30 - 6:30: Margarita European Inn located at 1566 Oak Ave., Evanston, IL (HIV, gonorrhea and chlamydia)

First Monday of each month: Pioneer Center, Child & Family Therapy Center located at 13707 W Jackson, Woodstock, IL 60098 (HIV)

Last Wednesday of every month: Unitarian Church of Hinsdale located at 17 W Maple St. Hinsdale, IL 60521 (HIV)

Meet me where I'm at in suburban Cook County (HIV, gonorrhea and chlamydia)

Meet me where I'm at in DuPage, Kane, Lake, McHenry, and Will counties (HIV)

Other:

When are you available for the free STI tests of your choice? We have very flexible appointments *

All STI tests require a counseling session to assess your specific needs. Due to COVID-19 we offer telehealth counseling sessions for less in-person contact time. Are you interested in a telehealth counseling session? *

Yes

Maybe

Other:

Safer sex kit deliveries are available for suburban Cook County residents. Would you like a safer sex kit delivery? *

Yes

Maybe

Other:

Are there any concerns regarding a discreet safer sex kit delivery to your place of residence?

Yes

Other:

Clear selection

Safer Sex Kit delivery address

Do you have any questions, comments, or concerns?

Submit

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