Participant Facing Concierge Enrollment Form

Customized education on PrEP treatment – developed to support those considering treatment and patients already on PrEP.

"*" indicates required fields

Answer the questions below so that we can send you the information that best meets your needs.

Are you a patient at CHI?*

Yes

Please enter your date of birth*

MM slash DD slash YYYY

Are you currently taking PrEP?*

Yes

No, but I am considering it and want to learn more.

How long have you been taking PrEP?*

I am just starting

Less than one year

1-3 years

More than 3 years

Which PrEP medication are you currently taking?*

Descovy

Truvada

Apretude

Other

You chose "Other", please specify*

Great! Now let’s learn a little bit more about you.

When thinking about starting PrEP treatment, there is a lot to consider including which PrEP treatment may be right for you based on gender, financial needs, and your personal care preferences, such as at-home testing, prescription delivery and more. The following questions will help us guide you in the right direction. Your information is kept completely private.

Great! Now let’s learn a little bit more about you.

EveryYou Concierge is designed to provide whole-person care personalized to our patient’s lifestyle and needs. The following questions will help us provide you with the right support most relevant to your treatment, needs and preferences. Your information is kept completely private.

Sexual Orientation

Do you think of yourself as

Straight or heterosexual

Lesbian or gay

Bisexual

Queer, pansexual, and/or questioning

Something else

Don’t know

Decline to answer

Please specify:

Gender Identity

What sex was originally listed on your birth certificate?

Male

Female

Decline to answer

Do you think of yourself as:

Male

Female

Transgender man/trans man

Transgender woman/trans woman

Neither exclusively male nor female (Genderqueer/gender nonconforming)

Something else

Don’t know

Decline to answer

Please specify:

Insurance and Living

What type of healthcare insurance do you have?

Uninsured

Medicaid

Managed Medicaid

Medicaid and Medicare

Medicare

Medicare & private insurance

Private insurance (including ACA)

Check the item below that best describes your lived environment.

This is so we can suggest plan of care options that will meet your privacy preferences and environmental needs:

I live in my own house or apartment by myself

I live in my own house or apartment with family

I live in my own house or apartment with friends

I live in the house or apartment of a family member

I live in the house or apartment of a friend or someone who is not family

I live in a homeless shelter

I am currently homeless

Almost done!

Name*

First Last

Please enter the mobile number you want us to send messages to:*

Terms and Conditions*

I agree to receive 1-5 text messages a week from the number 43386 and/or 1-866-376-6954. I understand that SMS text is not secure technology and that the messages I receive may include information related to this program, the nature of my condition, my care and/or services offered by EveryYou Health and my participating Community Health Center (CHC) provider.

I have fully read and agreed to the terms and conditions of this program.

**Please note that depending on your mobile phone service plan, message and data rates may apply. You may opt-out at any time by replying STOP to the text messages. You may also seek support by replying HELP to the text messages.

PrEP Concierge Enrollment

Sexual Orientation

Gender Identity

Insurance and Living

Almost done!