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 (Required.)

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Preferred Name (Chosen Name) (Required.)

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Date ofBirth (Required.)

Date

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Phone (Required.)

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How would you prefer for us to contact you? (Required.)

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Are you a person living with an HIV diagnosis? (Required.)

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Reason for appointment (Required.)

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Will you need support while attending this 1st appointment? (Required.)

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 50% of survey complete.

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