S.A.S.S.Y Brief Intake Form Please complete the following workName(Required) First Last Preferred NameBirth Date(Required) MM slash DD slash YYYY Gender(Required)FemaleTransgender FemaleMaleTransgender MaleNon-ConformingOtherEthnicity: Hispanic?(Required)YesNoRace(Required)Black/African AmericanAsianWhiteAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderOtherPerson Describe Self As:(Required)HeterosexualHomosexualBi-sexualTransgenderOtherRelationship Status(Required)SingleSingle living with PartnerMarriedDivorceSeparatedWidowedOtherPhone(Required)Email(Required) Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Living Situation:PermanentRentalOwnOn The StreetShelterGroup HomeTransitionalOtherEmergency Contact Number(Required)Name/Relationship(Required)Is emergency contact aware of client's HIV Status?(Required)Consent to Contact and Disclose information(Required)PhoneMailEmailAll of the AboveWhen were you diagnosed with HIV?(Required)Have you ever been diagnosed with AIDS(Required)Last Medical Visit(Required)Primary Care Provider(Required)Medication List(Required)Presenting Problems/Services Needed(Required)Consent I agree to the privacy policy.Proof of Status Drop files here or Select filesMax. file size: 100 MB.
