Referral Form - MCaresNJ

Please fill out the form below. The information you provide will assist us in providing you with the best care.

Legal Name *

Personal Name

Pronouns *

Gender Identity *

Date of Birth * Please note: MCaresNJ provides care to individuals who are 13 years or older.

Contact Information

Address *

County of Residence *

Email *

Phone Number *

Best Mode of Contact *

What are the best days/times for us to contact you?

Eligibility & Services

Eligibility Demographics *

I identify as part of the LGBTQ+ community.

I am a parent/guardian of an LGBTQ+ child.

I am a person living with HIV.

I have an increased likelihood of contracting HIV.

I choose not to disclose at this time.

Which services are you interested in? * (Check all that apply)

HIV Care Coordination (Provider, Insurance and Pharmacy Assistance, Social Services, etc)

LGBTQ+ Care Coordination (Gender Affirming Care, Legal Name Change and Social Services, etc.)

HIV/STI Testing and Prevention (Rapid Testing, Referrals, PrEP Navigation, Free Condoms, etc.)

Harm Reduction (Drug User Health Support, Overdose Prevention, Syringe Access, etc.)

Residential Services (Shelter, Housing, Utilities)

Behavioral Health Care (Outpatient Individual Counseling)

Support Groups

Additional Information

Important: MCaresNJ may take up to 5 business days to review online form submissions. We will contact you via your preferred method of communication as soon as possible. This form should not be used for immediate crisis needs. If you are having a mental health emergency, please call 911 or 988.

I acknowledge that I have read and understand the above statement. *

Provider REferrals

Partner with MCaresNJ

Request Services