RW Client Interest Form
This is not an emergency housing program. If you do not currently have a place to stay or if you are in danger of losing your housing, please contact the Housing Crisis Line: 804-422-5061
Please complete this form to request RW services at Health Brigade
Once you complete this form someone will reach out to you using the information you provide below within 2 business days to schedule your appointment. Please keep in mind we are closed Satudays & Sundays and most major holidays.
Full Name
*
First Name
Last Name
First choice method of contact
*
Phone call
Email
Second Choice method of contact
Phone call
Email
N/A
1. Phone Number
*
-
Area Code
Phone Number
1. Email
*
example@example.com
2. Phone Number
*
-
Area Code
Phone Number
2. Email
*
example@example.com
Services I am interested in
*
Goal setting, ongoing case management
Food vouchers
Transportation assistance
One time financial assistance
Services I am interested in
*
Goal setting, ongoing case management
Support group
Assistance with Ryan White unified eligibility
Assistance with getting HIV care or medications
Are you currently receiving HIV medical care?
*
Yes
No
Yes, but I need help switching Providers
Where are you currently receiving your HIV medical care?
*
VCU ID Clinic
The Daily Planet
Henrico Doctors Infectious Disease Specialist
Other
Have you ever received HIV medical care?
*
Yes
No
Where have you previously received HIV medical care?
*
VCU ID Clinic
Capital Area Health Network (Vernon J, Hayes Willis, etc)
Crossover Ministries
The Daily Planet
Henrico Doctors ID Specialists
Other
Are you currently taking HIV medications?
*
Yes
No
Do you need help getting refills of your HIV medication?
*
Yes
No
How much medication do you have left?
*
Less than one week supply
About a week's worth
About a month's worth
Other
Anything else you would like us to know?
OPTIONAL: If you have any documentation you need to upload, you can add it here
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