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AIDS Services Access Program
Thursday’s Child of Long Island AIDS Services Access Program
All information will be kept strictly Confidential.
 
Unique Client ID :
Legal Name :
if different :
Name you wish us to use
Address :
Town :
State : NY
ZipCode :
County: Suffolk County
Phone :
Cell :
Social Security Number (SSN):
Referral From:
Date of Application :
Date of Birth:
Gender :
Male Female Transgender
Are you currently employed? :
Yes No
HIV/AIDS Status (check only one) :
HIV+ CDC Defined AIDS HIV +, status unknown
Case Manager (if applicable):
Case Manager Phone:
How may we contact you? :
(check all that apply)
Race/Ethnicity:
Do you identify as Hispanic?
Yes No
Do you identify as GLB (Gay, Lesbian, Bisexual)?
Yes No
Are you a US Citizen?
Yes No
Are you a Resident Alien?
Yes No
Health Insurance :
Straight Medicaid
Medicare
HMO Medicaid
ADAP
No Insurance
NY State HMO
Other
 
Housing Type :
Single Parent, Female
Single Parent, Male
Two Parent Household
Two Adults, No Child
Single Female
Single Male
Housing :
Rental
Shared
Own (Mortgage)
Homeless
Other
 
Monthly Total Household Income $:
Total Family Size :
Member of House Hold Date of Birth Relationship Highest Education Level Monthly Income in $ Income Source
SELF
 
E - Employment EP – Employment plus other U - Unemployment SI - SSI
PA – PublicAssistance P - Pension HR - Home Relief SD - SSD
C - Child Support  O - Other A - Alimony


FLP %:
 
 
Thursday's Child, Inc.
80 Terry Street
Patchogue, New York 11772
Phone: 631.447.5044
Fax: 631.447.2494
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