Complete this form in its entirety as best as possible. Please use your legal name, name on ID. There is also a section for preferred name. Please contact info@truthprojecthtx.org if you need any assistance with completing the form.

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* Name

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* Preferred Name (Chosen Name)

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* Date ofBirth

Date

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* Phone

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* How would you prefer for us to contact you?

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* Are you a person living with an HIV diagnosis?

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* Reason for appointment

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* Will you need support while attending this 1st appointment?

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 50% of survey complete.

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