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). The first group will take place on July 12th, 2018. (Followed by August 9, September 13, October 11, November 8 and December 13, 2018.)

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, 212-423-9049, extension 312). Veronica is available Monday-Thursday from 10:00am to 4:00pm Eastern Time, and Friday from 10:00am to 2:00pm Eastern Time.

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

Name (Optional)

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* 1. Name (Optional)

Date of Birth

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* 2. Date of Birth

Date / Time
Zipcode

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* 3. Zipcode

Phone Number (Optional)

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* 4. Phone Number (Optional)

Primary Language (ex. English, Spanish, French)

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

Ethnicity

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* 6. Ethnicity

Race

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* 7. Race

Current Gender Identity

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* 8. Current Gender Identity

Sexual Orientation

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* 9. Sexual Orientation

What is your highest level of education?

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* 10. What is your highest level of education?

What is your current housing status?

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* 11. What is your current housing status?

Do you currently have health insurance?

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* 12. Do you currently have health insurance?

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

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

What is your HIV Status?

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* 14. What is your HIV Status?

In what year were you diagnosed with HIV?

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

How were you infected with HIV? (Optional)

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

Are you currently receiving treatment for your HIV?

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

Are you currently on HIV medication?

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* 18. Are you currently on HIV medication?

If known, what is your current CD4 count?

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

Do you currently have an undetectable viral load?

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

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

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

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

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* 22. 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 six months, I have felt lonely and isolated from the rest of the world because of my HIV status.
I feel empowered to advocate for myself when seeking HIV treatment
I avoid social gatherings and community events due to my HIV status.
I feel comfortable telling my friends and family about my HIV status.
I am excluded from family activities and social gatherings due to my HIV status.
Please mark the response that best describes how you feel about the following statements:

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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.
I feel comfortable telling members of my community (co-workers, members of your church, neighbors, etc.) that I have HIV.
I avoid spending time with my friends and family due to my HIV status.
I feel guilty or ashamed because of my HIV status.
I avoid going to the doctor or using social services because of my HIV status.
I feel like I can stand up for myself when I experience stigma or discrimination due to my HIV status.
Please mark the option that best describes how you feel about your life.

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

  Never Sometimes Always
I feel left out or alone.
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.
Have you told your friends and family that you are living with HIV?

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

Do you have friendships or relationships with other HIV-positive women?

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

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?

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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?

 

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