Care Connect – OHIV.org

Find HIV Care

Newly Diagnosed, new to Ohio, or an Ohio resident living with HIV and looking to get connected to services? Look no further! Complete the CareConnect form to have an care representative in your area contact you with assistance.

Consent for Service
By selecting "I Agree", you agree to have the information on this form shared with and to be contacted by a local HIV health navigator.
First Name*
Last Name*
Pronouns*
Please select how you would like someone to address you when they reach out:
Prounouns Cont.
If you selected "other" to the above question, please type your preferred pronouns:
Primary Phone*
If you do not have a phone number please input: 555-555-5555
Secondary Phone
(Optional)
Voicemail*
May we leave you a voicemail:
Email*
Enter Email Confirm Email
Best Way To Reach You?*
How should we get in touch?
Is it ok to text you?
- Yes
- No
In which Ohio county do you live?*
Please select from the drop down list
Date of Birth*
MM slash DD slash YYYY

Please input your Date of Birth.
Referral Source*
How did you find out about this program?
If you selected "Other" to the above question, please describe how your heard about this form
What was the community event?
What social media platform did you learn about CareConnect from?
Ex: Twitter, Facebook, Instagram, Grindr, etc.
Healthcare Organization
Please tell us the Health Care Organization you learned about PAPI from:
Accommodations
Do you require any accommodations such as a Translator, ASL Interpreter, or other assistance to work with a navigator?
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