top of page
DONATE
CLINIC SERVICES
(510) - 882 - 2286
HOME
Directory
ABOUT
Mission & History
Board
Staff & Volunteers
Job Opportunities
Our Office Space
Financial Statements
Press
CALENDAR
Calendar: support Groups + Activities
Legal Clinic
SERVICES
Aging With Pride
Black Men (BMAC)
Community Resources
Food Pantry
Glenn Burke Clinic
LatinX POWER X
Library
Mental Health Support
Narcotics Anonymous 12-Step
Rainbow Recovery Program
Rental/Housing Assistance
Rental Application
Sexual Health Testing
Support Groups
Transgender Support
Youth Program
SUPPORT US
VOLUNTEER
CONTACT US
Clinic REGISTRATION FORM
Clinic Days Are Mondays, Wednesdays, & Thursdays, for HIV/STI Testing & Treatment, (12pm-6pm)
For MPOX (monkeypox) vaccine clinic dates please see previous page.
For questions, please call our clinic between 12pm-6pm at
510-781-2639
Legal First Name (for insurance purposes)
Legal Last Name
Chosen Name
phone number
Email Address
Which City, State, or Country
Date of Birth
Please enter your city zip code
Have you tested postive for Covid-19 in the last 14 days?
No
Yes
What is your gender identity?
Transgender Woman
Transgender Man
Cis Gender Woman
Cis Gender Man
Non-Binary
Two-Spirit
Gender Non-Conforming
Other
N/A
What is your sexual orientation?
Bisexual
Lesbian
Gay
Heterosexual
Queer
Other
N/A
What is your race/ethnicity?
Are you low-income?
No
Yes
Please choose one or more of the following services:
Test/treatment for HIV/STI's/STD's
PEP or PrEP Enrollment
Injectable PrEP
MPOX (Monkeypox) Vaccine
Hormone Injection Assistance
Gender Care Referral
Linkage to primary care
Enrollment in a free or low cost healthcare program
Home HIV/STI Testing
Free Condoms & Lube
Transportation Assistance
Mental Health Support
Dental Care
Housing Assistance
Addiction/Treatment Support
Domestic Violence Support
Formerly Incarcerated - Re-entry Support
Other
Do you have private insurance? If yes, who is your provider?
How did you learn about us?
Click here
for income guidance
I declare that the info I’ve provided is accurate & complete
Submit
bottom of page