This page is for case managers who have clients who belong to the following groups:

  1. those who are HIV positive,
  2. sexual partners of those who are HIV positive, and
  3. those who are at higher risk of contracting HIV (including IV drug users and people with multiple sex partners who currently do not use condoms).

Complete the form below to sign up clients. Once this form has been submitted you will be contacted if additional information is required. Limit one offer per household/per address.

My client belongs to one of the high risk groups listed above
My client is 18 years or older
My client is a resident of Delaware

Case Manager Info:
Case Manager Name: *
Case Manager Phone:
Case Manager Email address: *
Client Info:
First Name: *
Last Name: *
Please enter last name.
Address: *
City: *
State: * Delaware
Zip Code: *
Day Phone:
Email address: *
Gender: * Male Female Trans
Year of Birth: * (4 digit number)
Please Select Condom Option (choose one only):*
Tan condoms & lube
Black condoms & lube
X-Large condoms & lube
Non latex condoms & lube
To order Female condoms (sample supply) or Dental Dams (sample supply), please note your request in the "Special Request" field.
Special Request:
 
 
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