• FAITH Intake Form

  • Welcome to the FAITH Program’s intake form! This form is designed to help us better understand your current needs and ensure you receive the support and services that align with your goals. Completing this assessment is an important part of starting your journey with FAITH, as it allows us to understand and connect you with the resources you need.

    Your responses will remain confidential and will only be shared with TKO staff and partner organizations directly involved in your care, as outlined in our confidentiality policy. If you have any questions or need assistance while completing this form, you can contact the TKO office for help at 334-593-2645.

  • Submission Date*
     - -

  • Client Information

  • Date of Birth*
     - -
  • Pronouns*
  • Format: (000) 000-0000.
  • How should staff members contact you to follow up on your interest in the FAITH program?*
  • Are there any days where it isn't good to contact you via phone call or text message? (Select all that apply.)
  • What time of day are we most likely to reach you by phone or text message?
  • Can we leave you a voicemail?

  • Demographic Information

  • What is your ethnicity?*
  • What is your race?*
  • How would you describe your gender identity?*
  • How would you describe your assigned-at-birth sex?*
  • How would you describe your sexuality/sexual orientation?*
  • Which of the following describe your housing situation over the last 12 months? (Select all that apply.)*
  • Which of the following best describe your employment status? (Select all that apply.)*
  • Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?*
  • Are you currently taking daily PrEP medication?*
  • Have you used PrEP at any time in the last 12 months?*
  • In the past 5 years, have you had sex with someone who identifies as male?*
  • In the past 5 years, have you had sex who identifies as female?*
  • In the past 5 years, have you had sex with someone who identifies as transgender?*
  • In the past 5 years, have you injected drugs or substances that have not been prescribed to you by a medical provider?*

  • Risk Assessment

  • How often do you discuss HIV status with your sexual partners?*
  • How would you describe your use of condoms?*
  • Have you had sex without a condom in the last month?*
  • Have you had sex without a condom in the last three months?*
  • Have you had sex without a condom in the last six months?
  • Have you been treated for an STD in the last six months?*
  • Have you worked as a sex worker in the last year?*
  • Do you currently share needles to inject drugs or substances?*

  • Needs Assessment

  • Do you have health insurance?*
  • Do you need assistance accessing mental health services?*
  • Do you need assistance accessing treatment for substance abuse disorders?*
  • Do you need access to any of the following other services?*
  • Should be Empty: