HRSEP Intake Form
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Member ID (First Initial, Last Initial, Birthday MM/DD/YYYY - EXAMPLE - BP02091986) *
Gender *
Sexual Orientation *
Required
Race *
Required
Hispanic *
Required
Marital Status
Clear selection
Highest level of education completed
Clear selection
Zip Code *
Are you Employed *
Health Insurance *
Drug of Choice *
Required
How many times per day do you usually inject *
Number of Syringes Collected *
Number of Syringes Provided *
Have you ever overdosed? *
Number of overdoses? *
Have been tested for Hep-C *
If tested, when was your last Hep-C Test?
Have been tested for Hep-B *
If tested, when was your last Hep-B Test?
Have you been tested for HIV *
If tested, when was your last HIV test?
Hepatitis A Vaccine? *
In the past 90 days have you been in any of the following? *
Required
Do you live with anyone who has a current drug or alcohol problem? *
Do you use drugs alone? *
Do you have access to Narcan? *
Please tell us how you heard about this program *
Required
Staff Name *
Notes
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