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Request for HIV Test Forms (Bubble Sheets)
HIV Early Intervention Services (EIS) Program
The Imagine Hope HIV Testing Program has a limited supply of rapid HIV testing supplies.
These are provided to partner agencies at no charge.
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Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Agency Name
*
Choose
Access Point
Advantage BHS
Alliance Recovery/Athens
Alliance Recovery/Conyers
Alliance Recovery/Decatur
Ascensa / St. Jude's
Aspire
Avita
Bridge Health
Brunswick Judicial Circuit Drug Court
CaringWorks
Clayton Center/PCLEC
CSB of Middle Georgia
CSB of Middle GA - Ogeechee
CSB of Middle GA - Quentin's Place
Coastal Behavioral Health
DeKalb County CSB
DM & ADR
Douglas County CSB
Fulton County Behavioral Health
Gateway BHS
Georgia Treatment Services
Highland Rivers Health
Highland Rivers/Cobb County CSB
Lanier Treatment Center
Legacy BHS
MARR Inc.
Med-Mark Treatment Centers / Chatswort
McIntosh Trail
Middle Flint
New Beginnings in Thomasville
Newport Intergrated
New Horizons CSB
New Horizons Nexus
North Fulton Treatment Center
Oconee
Odyssey Family Counseling Center
Pathways CSB
Pineland
Pittard Clinic
Recovery Consultants
Recovery Place
Reliance Treatment Center of Statesboro
Ringgold Treatment Center
Serenity BHS
Unison Behavioral Health
Unison Drug Court
Unison MAT
Viewpoint Health
Westcare of Georgia
Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Is this a New Address?
Yes
Number of Part 1 HIV Test Forms (Sheet 1 - Black, Sheet 2, Black & Purple: for ALL testing episodes)
Available in boxes of 100
Your answer
Number of Part 2 HIV Test Forms (Sheet 3 - Green: for confirmed HIV+ testing episodes)
We recommend that you keep at least 5 on hand
Your answer
Please allow two weeks for delivery
You will be notified by e-mail when your request can be filled.
A copy of your responses will be emailed to the address you provided.
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