Request edit access
Referral for CAP's Positive Steps Program
Cascade AIDS Project's Positive Steps program uses the evidence-based CLEAR (Choosing Life: Empowerment, Action, Results!) intervention to support people living with HIV/AIDS who are looking to make modifications in their lives. The participant-driven program is delivered one-on-one and uses cognitive behavioral techniques in order to support behavioral change.

If you want us to contact the participant you are referring, please fill out this survey. Any contact information you provide may be used to contact the participant.

We will do our best to respond to this referral within 48 business hours. Thank you!

Today's date *
MM
/
DD
/
YYYY
Full name of participant *
Participant's pronouns *
Please select participant's preferred means of contact *
Required
Participant's preferred contact information (ex. phone number, email address, physical address etc) *
Can we leave a message? *
Required
Does the participant know about this referral? *
Your relationship to the participant *
If you are not the participant, please provide your name, position title and contact information
Is there anything else you would like to share with us?
Thank you for taking the time to fill out this referral form. We will do our best to respond to this referral within 48 business hours.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service