Young Adult Client Intake Form (Internet Version) Please type in your responses, save this file and email to mars@gmad.org Or come into our office and fill out this form in person. Date / / First Name
Date of Birth / /
Last Name
Current Age
Middle Name Address Check one: Brooklyn /Queens /Bronx Other Phone
/Manhattan /Staten Island/ /New Jersey
Cell
Pager
Email address @
Check all that applies. How did you hear about The MARS Project? The GMAD Website Referral from another agency
Outreach information if so, which agency
Friend
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Missing DATA use: 9999 The purpose of this survey is to collect data, which focuses on “What are the perceived challenges that AAYMSMs face that inhibit their community mobilization, prevention and education efforts and increase their risks of infection and transmission of HIV/AIDS?”
[1[ Gender
[2] Sexual Orientation
1.Male 2.Female 3.Transgender (TG) 3.1M to F 3.2F to M 4.Other_______
[5] Race
1.Gay/Lesbian 2.Bisexual 3.Heterosexual 4.Down Low (DL) 5.Questioning 6.Men who have Sex with Men (MSM) 7.Same Gender Loving (SGL) 8.Other
[6] Enter the Zip code you reside in
1.African American/Black 2.Asian Amer/Pac. Is./Filipino 3.Caucasian/White 4.Native Amer/ Amer. Ind. 5.Mixed Heritage 6.Other
[3] Age
[4] Ethnicity
1.13-16 2.17-20 3.21-24 4.25-36 5.37-49 6.50 & over
1.Hispanic 2.Not Hispanic/Latino 3.Ethnicity Unknown
[7] Highest Education
[8] HIV Status
1.Some High School 2.High School 3.GED 4.Some College 5.College 6.Post Grad 7.Other_____
1.Positive 2.Negative 3.Don’t Know 4.Prefer not to answer
9. Do you believe that Black Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG are members of your Community? (Check all that apply) Black Gay Black Bisexual Black Bi-curious Black DL MSM 7.1Yes Black SGL Black TG
7.1Yes 7.2Yes 7.1Yes 7.1Yes 8.1No 7.1Yes 7.1Yes
8.1No 9.1Don’t Know 8.2No 9.2Don’t Know 8.1No 9.1Don’t Know 8.1No 9.1Don’t Know 9.1Don’t Know 8.1No 9.1Don’t Know 8.1No 9.1Don’t Know
Black
10. Do you feel isolated from the gay community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
11. Do you associate with the Black Gay community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
12. Do you believe that Black Gay, Bisexual, Bi-curious, MSM/ SGL/TG people are isolated within the Black Community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
13. Can a person identify as a Black/Gay Male/Same Gender Loving Male and still be comfortable with themselves?
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5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
14. Do you find it difficult to identify as a Black, Gay Male? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
15. Do you feel comments from rappers like Ice Cube “Real niggers ain’t gay!” represent African American beliefs? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
16. Do you perceive African American communities to be more homophobic than other ethnic communities? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
17. Do you believe that a Black Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG person can be comfortable being Out to their Family in the Black Community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
18. Rejected by mainstream community is a possible barrier to being a part of the Black Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG Community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
19. Lack of identification with the community is a possible barrier to being a part of the Black Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG Community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
20. Not being able to “come-out” is a possible barrier to being a part of the Black Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG Community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
21. How do you see yourself primarily by race/ethnicity, gender identity, or by sexual orientation? 1. Race/Ethnicity (e.g. Black, Latino, etc) 1. Yes 2. No 2. Sexual Orientation 1. Yes 2. No 3. Transgender 1. Yes 2. No 4. Other 1. Yes 2. No
SGL=Same Gender Loving, DL=Down Low, TG=Trans Gendered 22. Physical or verbal abuse is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
23. Estranged from my family & black culture is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG?
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5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
24. Condemnation by church or faith-based organizations is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
25. My sexual orientation Conflicts with my racial/ethnic identity and is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
26. My sexual orientation Conflicts with my gender identity and is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
27. Physical or verbal abuse is a perceived risk for people who publicly identify as Gay, Bisexual, Bi-curious, DL/MSM/ SGL/TG? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
28. Do you feel that by having sexual orientation as a label/category that this is a barrier for a cohesive community? 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
29. Do you identify as Down Low (DL) in the Black Gay community? (See question 2) 5.Strongly Agree
4.Somewhat Agree
3.Neutral
2.Somewhat disagree
1.Strongly disagree
30. Rate your level of safety in the Black Community? 1. Un-Safe
2. Moderately Safe
3. Safe
4. Very Safe
31. Would you be interested in doing further work in community mobilization? 1. Yes
2. No
3. Don’t Know
What other topics would you suggest for future workshops? Thank you! Your answers will help GMAD plan future programs. REMEMBER, SAVE this file and email to MARS@GMAD.ORG.
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