HIV Social Support Self Referral Form

YorSexualHealth (YSH) runs a free and confidential support service for people living with HIV and their partners and carers in York and North Yorkshire.

We can support with:

• Self-management of your physical and mental health
• Assistance with benefits and getting back into work or education
• Peer support and group support opportunities
• Symptoms management 

To refer into the service, please fill in the form below. 

Name: *

Date of birth: *

Gender: *

Postcode: *

Email address: *

Phone number: *

I prefer to be contacted by: * Phone Email

Can we leave a voicemail?: * Yes No

Can we send a text message?: * Yes No

The best time to get in contact (if by phone) is: