Hugh's Kitchen Request Form
Please complete this form to request assistance with food and hygiene products.  
Our program serves LGBTQ and HIV community members, primarily in Allegheny County.  We offer scheduled grocery pick-up at our offices at 925 Brighton Road Pittsburgh, PA 15233 Wednesday-Friday.  A HLWF staff member will follow-up with you to verify eligibility for our services and schedule a visit. 

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Email *
What is your name? *
Please provide First and Last Name (eg "Jamie Smith")
What are your pronouns?
Do you identify as part of the LGBTQ+ & HIV communities? *
What best describes your sexual orientation?
 *
Please select all that apply.
Required
We know the terms from the last question may not represent everyone. If you'd like to describe your sexual orientation in your own words, please do so here:
Do you identify as intersex?
Clear selection
Do you identify as transgender?
Clear selection
Which of the following best describe(s) your gender identity?
 *
Please select all that apply.
Required
We know the terms from the last question may not represent everyone. If you'd like to describe your gender identity in your own words, please do so here:
Have you experienced food insecurity?  (not having enough food) *
What's your birth day? *
Please include Month Day and Year. (eg. MM/DD/YYYY)
Would you like to access additional resources and verify eligibility for Ryan White - HIV services? *
Do you have any dietary needs or restrictions? *
We will do our best to accommodate but cannot make any guarantees.  
Do you have a can opener? *
How frequently would you like to pick up resources?   *
Which location would you like to pick up from? *
Please select the items that you need *
Required
What is the best contact phone number to reach you? *
Please provide 10-digit phone number including area code. XXX-XXX-XXXX
May we text the phone number provided? *
What is your address? (we want to know who we are serving) *
Please include your street number, street name, city, and zip code.  
Would you like to be added to our mailing list to stay up to date on new resources and upcoming events, to make sure you get details first?   *
How did you learn about Hugh's Kitchen?
Clear selection
Please make sure you provide the best method to connect with you.
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