Support Group Request

PROVIDE ID
I am attending as:
Welcome!

Thank you for your interest in joining our Support Groups for People Living with HIV. These groups are safe, empowering, and judgment-free spaces designed to support you through community, connection, and shared experience. Whether you're seeking emotional support, education, or simply a space where you can be seen and heard, you are welcome here.

You may sign up for one or more groups that speak to your needs and interests. After submitting your request, a staff member from the Minority Health Consortium (MHC) will contact you to follow up and help you get connected.

Please note: All participants will be required to provide proof of HIV diagnosis before attending any support group. This is to ensure that our spaces remain focused, safe, and relevant for all participants.

Your information will be kept private and confidential at all times. We’re honored to walk this journey with you.

You belong here. You are not alone. Welcome to the community.

MY HIV status is:*
I receive my HIV care:*
If other, please specify*
Would you like MHC to assist you in finding a new HIV medical provider?*

Name*

First NameMiddle NameLast Name
Address*

Street Address & Apt #

CityState / Province
Zip code*
Email*

Confirmation EmailConfirm your Email address
Phone*

Sex at Birth*
I identify as:*
Your age range:*
Current Age*

Which group are you interested in attending? Click all that apply:

Community Advisory Board "CAB"Positive Brotherhood+ QueensAll InclusiveVACAC Learning Group
CONFIDENTIALITY AGREEMENT

As a participant of support groups and events, associated with Minority Health Consortium, hereinafter referred to as MHC: I acknowledge and understand that I will be in the company of other HIV positive individuals.

Therefore, I agree to the following "Disclosure of Information" Confidentiality agreement: Disclosure of Information is defined as but is not limited to, verbal discussion, fax transmissions, electronic transmission, voice communication, written documentation.

After attending an MHC support group or event, I will not disclose another participant's personal or medical information regarding their diagnosis to any other person who did not attend. I understand that it is the policy of MHC to protect the confidentiality of all information particularly related to retreat members.

I understand that I will be held responsible for the consequences of any misuse of information gained from my participation with MHC support group or event. I will respect the confidentiality of all retreat members, private or sensitive information accessed in any MHC support group meeting, event or private conversation.

Iwill not disclose the Identity of other MHC support group or event members.

I agree to follow the confidentiality policies and procedures established by MHC. Failure to follow the confidentiality policies and procedures will result in the revocation of my privileges to attend any future MHC support groups or events and/or disciplinary action(s) including criminal charges. By signature below indicates that I have read, understand, and agree to abide by the terms and conditions of this Confidentiality Agreement.

Participant Contract and Waiver

If I am invited to participate in The Minority Health Consortium "MHC" support group or event, I understand that there are certain behaviors and activities which are appropriate. Therefore, during these support groups / events,

I PROMISE TO:

1. Participate fully in all activities as much as my health permits. 2. Be on time for all scheduled meetings and group activities. 3. Be considerate and helpful to others. 4. Be free of drug and alcohol use or possession. I understand if I break this promise I will be required to leave immediately and at my own expense. 5.Not smoke in any of the buildings. 6.Neither make nor receive telephone calls, except-if you must- Step outside of the meeting area. 7.Respect the confidential nature of all aspects of the MHC meetings and events. 8. Respect different belief systems and refrain from evangelical activities (proselytizing 9.Not take items that are not given to me. I understand if I break this promise I will be required to leave immediately and at my own expense and could be banned from attending future MHC support groups or events.

10. Attend at my own risk. MHC not liable for injury or incidents that occur during support groups / events.

I have read and understand the expectations of an MHC support group / event participant. I promise to abide by the rules and fulfill these expectations to the best of my ability.
Do you agree with the Confidentiality Agreement?*

Do you give MHC permission to obtain your HIV medical information for Ryan White eligibility purposes.*
Would you like to receive information about upcoming MHC events?*
Signature*

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