Love Your Life Support Virtual Group Intake

Please read before completing the intake:

Thank you for your interest in the Love Your Life Support Group! This is a virtual support group for women living with HIV across the United States. You will be able to access this group either on your telephone (cellphone or landline) or through your computer. This group is being managed by Iris House, a non-profit organization located in Harlem, NY. For more information about Iris House, visit our website: www.irishouse.org

In this support group trained professionals will be facilitating discussions about a series of topics, including: HIV treatment, disclosure, relationships, sex, stigma, family, empowerment, mental health, and more. Group participants will have the opportunity to join the discussion and talk about their experiences if they would like to. However, if someone does not want to participate in the discussion or share their personal information, they will not be forced to do so. Participants can join the group just to listen if that is their preference.

The Love Your Life support group will take place on the second Thursday of every month from 7:00pm – 8:00pm Eastern Time (6:00-7:00 Central Time, 5:00-6:00 Mountain Time, 4:00-5:00 Pacific Time).

If you are interested in participating in the group you must fill out the following intake form. Please note that the information you provide in this form will be completely confidential and will not be shared with any other members of the group. After you complete these forms, you will be given information about how to access the support group.

This intake process should take about 15-20 minutes. There is no way to save the intake and return to it, so please complete it in one sitting.

If you have any further questions or would prefer to complete your intake over the phone, please contact Veronica Karp (vkarp@irishouse.org)

Questions with * are required. All other questions are optional.

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1. Name (Optional)

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2. Date of Birth (Required.)

Date / Time

Date

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3. Zipcode (Required.)

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4. Phone Number (Optional)

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5. Primary Language (ex. English, Spanish, French) (Required.)

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6. Ethnicity (Required.)

Hispanic

Non-Hispanic

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7. Race (Required.)

Asian

Black/African American

Native American

Native Hawaiian/Pacific Islander

White

Other (please specify)

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8. Current Gender Identity (Required.)

Cisgender Female *(Cisgender is a term describing a person who's gender identity matches the sex they were born. A person who is not transgender.)

Transgender Female

Other (please specify)

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9. Sexual Orientation (Required.)

Straight

Gay

Lesbian

Bisexual

Pansexual

Other (please specify)

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10. What is your highest level of education? (Required.)

Elementary School

Junior High School

Some High School

High School/GED

Some College

Associate Degree

Bachelor's Degree

Graduate Degree

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11. What is your current housing status? (Required.)

Permanent Housing (Rent/Own)

Homeless on Street

Homeless in Shelter

Transitional Housing

Residential Psychiatric Facility

Residential Drug Treatment Facility

Correctional Facility (Halfway House)

With Friends/Relations

Other (please specify)

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12. Do you currently have health insurance? (Required.)

Yes, Medicaid or Medicare

Yes, Private Insurance

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13. In the past 12 months have you (Check all that apply):

Been in jail/prison

Used injection drugs

Been a sex worker

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14. What is your HIV Status? (Required.)

HIV-Positive

HIV-Negative

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15. In what year were you diagnosed with HIV? (Required.)

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16. How were you infected with HIV? (Optional)

Heterosexual Contact

Same Sex Contact

Sharing Drug Needles

Mother to Infant

Blood Transfusion

Other (please specify)

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17. Are you currently receiving treatment for your HIV? (Required.)

Yes

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18. Are you currently on HIV medication? (Required.)

Yes

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19. If known, what is your current CD4 count?

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20. Do you currently have an undetectable viral load? (Required.)

Yes

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21. How did you hear about this group? (Check all that apply) (Required.)

A friend or family member

A caseworker or social worker

A doctor or medical professional

Facebook

Twitter

Instagram

A flyer

Voces Latinas

WORLD

The Afiya Center

Iris House

Minority AIDS Council

Other (please specify)

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22. Please mark the response that best describes how you feel about the following statements: (Required.)

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status.	In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status. Strongly Disagree	In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status. Disagree	In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status. Neither Agree nor Disagree	In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status. Agree	In the past six months, I have felt lonely and isolated from the rest of the world because of my HIV status. Strongly Agree
I feel empowered to advocate for myself when seeking HIV treatment	I feel empowered to advocate for myself when seeking HIV treatment Strongly Disagree	I feel empowered to advocate for myself when seeking HIV treatment Disagree	I feel empowered to advocate for myself when seeking HIV treatment Neither Agree nor Disagree	I feel empowered to advocate for myself when seeking HIV treatment Agree	I feel empowered to advocate for myself when seeking HIV treatment Strongly Agree
I avoid social gatherings and community events due to my HIV status.	I avoid social gatherings and community events due to my HIV status. Strongly Disagree	I avoid social gatherings and community events due to my HIV status. Disagree	I avoid social gatherings and community events due to my HIV status. Neither Agree nor Disagree	I avoid social gatherings and community events due to my HIV status. Agree	I avoid social gatherings and community events due to my HIV status. Strongly Agree
I feel comfortable telling my friends and family about my HIV status.	I feel comfortable telling my friends and family about my HIV status. Strongly Disagree	I feel comfortable telling my friends and family about my HIV status. Disagree	I feel comfortable telling my friends and family about my HIV status. Neither Agree nor Disagree	I feel comfortable telling my friends and family about my HIV status. Agree	I feel comfortable telling my friends and family about my HIV status. Strongly Agree
I am excluded from family activities and social gatherings due to my HIV status.	I am excluded from family activities and social gatherings due to my HIV status. Strongly Disagree	I am excluded from family activities and social gatherings due to my HIV status. Disagree	I am excluded from family activities and social gatherings due to my HIV status. Neither Agree nor Disagree	I am excluded from family activities and social gatherings due to my HIV status. Agree	I am excluded from family activities and social gatherings due to my HIV status. Strongly Agree

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23. Please mark the response that best describes how you feel about the following statements:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status.	In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status. Strongly Disagree	In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status. Disagree	In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status. Neither Agree nor Disagree	In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status. Agree	In the past 6 months, I have confronted or educated someone who was discriminating against me due to my HIV status. Strongly Agree
I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV.	I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV. Strongly Disagree	I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV. Disagree	I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV. Neither Agree nor Disagree	I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV. Agree	I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV. Strongly Agree
I avoid spending time with my friends and family due to my HIV status.	I avoid spending time with my friends and family due to my HIV status. Strongly Disagree	I avoid spending time with my friends and family due to my HIV status. Disagree	I avoid spending time with my friends and family due to my HIV status. Neither Agree nor Disagree	I avoid spending time with my friends and family due to my HIV status. Agree	I avoid spending time with my friends and family due to my HIV status. Strongly Agree
I feel guilty or ashamed because of my HIV status.	I feel guilty or ashamed because of my HIV status. Strongly Disagree	I feel guilty or ashamed because of my HIV status. Disagree	I feel guilty or ashamed because of my HIV status. Neither Agree nor Disagree	I feel guilty or ashamed because of my HIV status. Agree	I feel guilty or ashamed because of my HIV status. Strongly Agree
I avoid going to the doctor or using social services because of my HIV status.	I avoid going to the doctor or using social services because of my HIV status. Strongly Disagree	I avoid going to the doctor or using social services because of my HIV status. Disagree	I avoid going to the doctor or using social services because of my HIV status. Neither Agree nor Disagree	I avoid going to the doctor or using social services because of my HIV status. Agree	I avoid going to the doctor or using social services because of my HIV status. Strongly Agree
I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status.	I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status. Strongly Disagree	I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status. Disagree	I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status. Neither Agree nor Disagree	I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status. Agree	I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status. Strongly Agree

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24. Please mark the option that best describes how you feel about your life. (Required.)

	Never	Sometimes	Always
I feel left out or alone.	I feel left out or alone. Never	I feel left out or alone. Sometimes	I feel left out or alone. Always	I feel left out or alone.	I feel left out or alone.
I have people I feel comfortable asking for help at any time.	I have people I feel comfortable asking for help at any time. Never	I have people I feel comfortable asking for help at any time. Sometimes	I have people I feel comfortable asking for help at any time. Always	I have people I feel comfortable asking for help at any time.	I have people I feel comfortable asking for help at any time.
I have a place I can go where I can vent and discuss my problems.	I have a place I can go where I can vent and discuss my problems. Never	I have a place I can go where I can vent and discuss my problems. Sometimes	I have a place I can go where I can vent and discuss my problems. Always	I have a place I can go where I can vent and discuss my problems.	I have a place I can go where I can vent and discuss my problems.

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25. Have you told your friends and family that you are living with HIV? (Required.)

Yes

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26. Do you have friendships or relationships with other HIV-positive women? (Required.)

Yes

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27. In order to access the support group, we need to send you a link to the website or a phone number for you to call. How would you like us to deliver this information to you? (Required.)

Call me on the phone.
(Please provide us with your phone number and the best time of day for us to reach you).

Email me.
(Please provide us with your email address).

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* 1. Name (Optional)

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* 2. Date of Birth (Required.)

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* 3. Zipcode (Required.)

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* 4. Phone Number (Optional)

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* 5. Primary Language (ex. English, Spanish, French) (Required.)

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* 6. Ethnicity (Required.)

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* 7. Race (Required.)

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* 8. Current Gender Identity (Required.)

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* 9. Sexual Orientation (Required.)

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* 10. What is your highest level of education? (Required.)

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* 11. What is your current housing status? (Required.)

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* 12. Do you currently have health insurance? (Required.)

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* 13. In the past 12 months have you (Check all that apply):

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* 14. What is your HIV Status? (Required.)

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* 15. In what year were you diagnosed with HIV? (Required.)

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* 16. How were you infected with HIV? (Optional)

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* 17. Are you currently receiving treatment for your HIV? (Required.)

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* 18. Are you currently on HIV medication? (Required.)

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* 19. If known, what is your current CD4 count?

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* 20. Do you currently have an undetectable viral load? (Required.)

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* 21. How did you hear about this group? (Check all that apply) (Required.)

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* 22. Please mark the response that best describes how you feel about the following statements: (Required.)

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* 23. Please mark the response that best describes how you feel about the following statements:

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* 24. Please mark the option that best describes how you feel about your life. (Required.)

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* 25. Have you told your friends and family that you are living with HIV? (Required.)

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* 26. Do you have friendships or relationships with other HIV-positive women? (Required.)

Question Title

* 27. In order to access the support group, we need to send you a link to the website or a phone number for you to call. How would you like us to deliver this information to you? (Required.)

1. Name (Optional)

2. Date of Birth (Required.)

3. Zipcode (Required.)

4. Phone Number (Optional)

5. Primary Language (ex. English, Spanish, French) (Required.)

6. Ethnicity (Required.)

7. Race (Required.)

8. Current Gender Identity (Required.)

9. Sexual Orientation (Required.)

10. What is your highest level of education? (Required.)

11. What is your current housing status? (Required.)

12. Do you currently have health insurance? (Required.)

13. In the past 12 months have you (Check all that apply):

14. What is your HIV Status? (Required.)

15. In what year were you diagnosed with HIV? (Required.)

16. How were you infected with HIV? (Optional)

17. Are you currently receiving treatment for your HIV? (Required.)

18. Are you currently on HIV medication? (Required.)

19. If known, what is your current CD4 count?

20. Do you currently have an undetectable viral load? (Required.)

21. How did you hear about this group? (Check all that apply) (Required.)

22. Please mark the response that best describes how you feel about the following statements: (Required.)

23. Please mark the response that best describes how you feel about the following statements:

24. Please mark the option that best describes how you feel about your life. (Required.)

25. Have you told your friends and family that you are living with HIV? (Required.)

26. Do you have friendships or relationships with other HIV-positive women? (Required.)

27. In order to access the support group, we need to send you a link to the website or a phone number for you to call. How would you like us to deliver this information to you? (Required.)