HIV Take Home Test

Have you had an HIV test before? *YesNoDon't Know

Within the last 5 years have you had (check all that apply) *Unprotected vaginal or anal sex with a maleUnprotected vaginal or anal sex with a femaleUnprotected vaginal or anal sex with a transgender individualInjected drugs or substances

Have you ever heard of Pre-Exposure Prophylaxis (PrEP)? (Note: PrEP is a daily pill that can prevent HIV.) *YesNo

Which best describe your use of Pre-Exposure Prophylaxis (PrEP)? *I take PrEP once a day as prescribedI was taking PrEP, but not nowI don't know what PrEP isI have never taken PrEP

Date of Birth *

Country of Origin *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

First Name *

Last Name

What are your pronouns? (select all that apply) *He, Him, HisShe, Her, HersThey, Them, TheirsSomething else (indicate below)

My pronouns are:

Phone Number *

May We Text You? *YesNo

Email Address *

What is your preferred method of contact? *EmailCallText

Would you be interested in Tele-Testing? This means, we would walk you through the process through video or phone call on a secure network. This allows you to have any questions you may have answered regarding safer sex practices and ways to reduce your risk of contracting HIV and other sexually transmitted infections (STIs). If you are interested in PrEP (Pre-Exposure Prophylaxis), our PrEP Navigator, Jason, can start the referral process with you and answer any questions regarding the start of PrEP. When you check off yes below, we will use the information you've provided us to reach out via email or text so we can set up an appointment with you and send the link or additional information needed to log on with one of our Community Outreach Workers. *YesNo

I understand that I need to contact Apex with my results within 10 days of receiving the kit. (You can call us at 203-778-2437 or email us: prevention@apexcc.org) *I understand

I Am Not a Robot *Check Box

Welcome back,