Tell us about yourself...

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Breaking Barriers Admission Survey

Email *

What is your name? *

Are you a self-identifying woman living with HIV? *

Yes

What do you wish you obtain from this support group? *

To receive information and updates on latest HIV research/news.

To make connections with other women living with HIV.

To receive advice from other women living with HIV.

To receive updates on upcoming virtual (COVID-friendly) events related to HIV.

All of the above.

Other:

By joining the support group Breaking Barriers, I acknowledge and hereby agree that ICW will NOT be held responsible for any breech of confidentiality that is beyond the control of the moderators. That being said, this support group is designed to be a private group made up of only self-identifying women living with HIV. No information is to be shared outside of the group without consent from the individual. *

Agree

Disagree

For the purpose of adding you to the Telegram support group, what is your phone number (including area code)? *

Submit

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