The Initiative For Equal Rights
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Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Self-Test Kit Eligibility Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Age
Email
*
Phone Number
*
Have you had any recent exposure to HIV?
Yes
No
Have you had a HIV Test done in the last three(3) months?
Yes
No
What key population do you identify with
*
Men Who Have Sex With Men (MSM)
Female Sex Workers (FSW)
Injecting Drug Users (IDU)
Transgender
Others
If others, please explain
*Please note that only eligible candidates will be contacted. Contact will be made in 48 hours. Ineligible applicants can make an appointment for an inhouse facility-based test in any of our facilities
Submit
