Refer Yourself to HIV Support Services

Full name * Mobile * Email * Are you living with HIV? * What is your postcode? *

Please be aware that we only cover Bradford Metropolitan District postcode areas.

How old are you? * How do you describe your gender? * If you selected other, please specify Is this the gender you were assigned at birth? Do you have a disability? * If yes, what disability or disabilities do you have?

We will contact you for more information and if we need to make any adjustments Please be aware that we only cover Bradford Metropolitan District postcode areas.

Do you have any mental health or neurodivergent conditions (anxiety, dyslexia, autism etc.) * What is your living circumstance? How will you get to our office? * Are you registered with an HIV clinic in the UK? Do you have enough medication? What is the main issue/s you would like to resolve with our support? * What days and times are most convenient for you? * Are you able to communicate easily in English? * If No, what language do you speak? Do you have mobility issues? * Are there any adjustments that you need us to make for you? I have read and understood the Yorkshire MESMAC privacy statement and agree to the use of my data in line with this policy *

Find link to privacy policy at the bottom of the page