Request For Care

This field is hidden when viewing the form

Our goal is to connect you to care within 72 hours.

Services are inclusive and confidential. Connect with care and support that puts your needs first.

Name*

First Name Last Name

E-Mail*

County*

We are unable to offer services outside the listed counties.

Ethnicity

Phone*

Date of Birth*

Please select how we may be of service to you: (select all that apply)*

What other service may we help you with?

Notes

Do not enter any HIPAA protected info

When is the best time to contact you?

Morning
Afternoon
Evening

This field is hidden when viewing the form

Take Control HIV community provides linkage to HIV prevention and care services across Pennsylvania. By completing this form, you are granting permission for the Take Control HIV community to access the information you provide and to contact you. Follow up is typically provided within 72 hours.

Acknowledgement

I consent to be contacted

This field is hidden when viewing the form

Terms and Conditions

I consent to the Terms and Conditions

This field is hidden when viewing the form

Survey

You may contact me with a survey

This field is hidden when viewing the form

Assign To

This field is hidden when viewing the form

Status

This field is hidden when viewing the form

Date Contacted

This field is hidden when viewing the form

Region

Phone

This field is for validation purposes and should be left unchanged.

Request for Care

Our goal is to connect you to care within 72 hours.