Becoming a Client

Interested in becoming a client? Double-check the eligibility requirements below, then do one of the following: 

• Fill out the e-application below
• Print out an application and mail or fax attn: Intake Coordinator at 541-342-1150
• Request an application be mailed to you by calling the Intake Coordinator at 541-342-5088

We cannot guarantee the security of the email provider you are using. If you do not want to email your request for intake, please contact our Intake Coordinator at 541-342-5088 or toll free at 1-866-470-3419.

Eligibility

• People living with HIV/AIDS in Coos, Curry, Josephine or Lane counties are eligible for Care Coordination.
• People living with HIV/AIDS in Coos, Curry, Josephine or Lane counties are eligible for RN Case Management based on medical need.

*Please note that eligibility for Emergency Financial Assistance is based on income.

Steps to Becoming a Client

Once you contact the Intake Coordinator they will complete the initial Intake. You will be mailed an Intake Packet to complete and return. You will need to provide HIV Verification and proof of income and residency. The Intake Coordinator will schedule an appointment with a Care Coordinator for screening and with a RN for Assessment.

1. Submit form or contact Intake Coordinator
2. Complete Intake
3. Provide HIV Verification
4. Provide Income Verification
5. Provide proof of residency
6. Complete and return the Intake packet
7. Complete Care Coordination Screening and RN Assessment

Questions? More information?

Michelle O'Leary

Intake Coordinator

541-342-5088 x 108