 |  |
Please use this form to tell us about your organisation.
Please use this form to let us know about your organisation. When it is complete please return it by email to paul@nam.org.uk or post it to the address at the bottom of the form. If you have any questions about how to fill this form please call Paul on 020 3242 0829
Contact Details
| Your details | |
|---|---|
| Your organisation’s name | |
| Agency or department name | |
| Full NHS trust name (if applicable) | |
| Catchment area for your services (eg East Ayrshire, UK-wide, open access) | |
| Local council area | |
| Your main phone number | |
| Your main email address | |
| Your main fax number | |
| Your website | |
| Organisation’s Twitter username | |
| Organisation’s Facebook url | |
| Organisation’s Youtube username | |
| Organisation’s Blog url | |
| Postal address of your organisation | |
| Full postcode |
Outreach addresses
If you provide services from locations other than your main address, please include the addresses of these locations here.
NAM key contact
This should be the best person for NAM to contact in future in order to update your details.
This information is not publicly available but we may share it with other organisations in the sector.
| Contact details | |
|---|---|
| Name | |
| Job Title | |
| Telephone | |
| Email address |
Languages
Do you offer services in languages other than English?
| Language (e.g. French) | Service (e.g. counselling) |
|---|---|
Description
Please tell us the service details for your organisation.
We would like:
- a short description of your service
- a list of key staff
- details of drop-in times, or times when no appointment is needed
- details of any key services
Short description of your service
Key staff
| Job title | Name | Contact details (contact numbers/email) |
|---|---|---|
Appointments & drop-in times
Please give details of any times when you operate a walk-in/drop-in service or one when it is not necessary to have an appointment.
Services you provide
Please add as many services as you need to.
| Service 1 | |
|---|---|
| Name of service | |
| Brief description | |
| Staff | |
| Times | |
| Service 2 | |
| Name of service | |
| Brief description | |
| Staff | |
| Times | |
| Service 3 | |
| Name of service | |
| Brief description | |
| Staff | |
| Times | |
| Service 4 | |
| Name of service | |
| Brief description | |
| Staff | |
| Times | |
Do you have disabled access?
| Yes No |
Your registered charity number?
Indexing
How your organisation is indexed determines how easily it can be found on our database by people looking to contact you.
Please think carefully about which index terms apply to you.
If you are updating your details the index terms that have the ‘Yes’ box shaded are provided as a guide, they are the index terms you chose last time you updated.
Please tick Yes or No to all of the boxes
Do you provide bespoke or specially designed services for any of the following groups of people?
| Yes | No | |
|---|---|---|
| Transgender people | ||
| UK African population | ||
| Carers | ||
| Children | ||
| Minority ethnic groups & migrant populations | ||
| Gay men | ||
| Haemophiliacs/recipients of blood products | ||
| LGBT (lesbian, gay, bisexual & transgendered) people | ||
| Men (but not specifically gay men) | ||
| Men who have sex with men | ||
| Prisoners or their families | ||
| Couples with differing HIV status | ||
| Sex workers | ||
| Women | ||
| Young people |
What type of organisation are you?
| Yes | No | |
|---|---|---|
| Are you a lobbying and campaigning organisation for HIV, HIV treatment and related policy issues? | ||
| Are you an organisation whose main focus is dealing with alcohol and drugs misuse? | ||
| Are you a religious or faith group which provides specific HIV & related services? | ||
| Are you a government organisation or public body involved in HIV related services such as monitoring or regulation? | ||
| Are you responsible for commissioning or coordinating HIV & related services? | ||
| Are you part of local authority social services' provision? | ||
| Are you a non governmental organisation? | ||
| Do you provide community-based, professional or peer-to-peer education, contact or support? | ||
| Are you involved projects and services designed to prevent HIV transmission? | ||
| Does your organisation represent members of a particular professional group? | ||
| Is your organisation a sexual health clinic or do you provide one? |
If you provide any sexual health services please fill the box below
| Yes | No | |
|---|---|---|
| Does your service provide HIV testing? | ||
| Does it provide instant/point of care HIV tests? | ||
| Does it provide rapid HIV tests (results the same day)? | ||
| Does it provide 4th Generation/Duo HIV tests? | ||
| Does your service have a hepatitis co-infection clinic? | ||
| Does your service have a tuberculosis clinic? | ||
| Does your service have a clinic that is specifically for young people? | ||
| Does your service have a clinic that is specifically for gay men? | ||
| Does your service provide HIV treatment? | ||
| Does your service treat or manage opportunistic infections? | ||
| Do you treat or manage conditions other than HIV/AIDS, or common opportunistic infections? |
All organisations: please tell us about the services you provide
| Yes | No | |
|---|---|---|
| Do you provide advice & advocacy on rights and entitlements for individuals? | ||
| Does your organisation run clinical trials? | ||
| Do you provide a complementary therapy, such as acupuncture, massage, osteopathy or another? | ||
| Do you distribute and/or promote condoms? | ||
| Do you provide counselling delivered by trained personnel? | ||
| Do you provide services that are designed for people who misuse drugs and/or alcohol? | ||
| Do you provide, or advise on, family planning? | ||
| Do you provide financial assistance for individuals, groups or organisations? | ||
| Do you provide healthcare or medical support based in the community rather than a clinical setting? | ||
| Do you provide services designed to enable people to increase their control over and improve their health? | ||
| Do you provide a designated helpline? | ||
| Do you provide a service related to hepatitis? | ||
| Does your service provide HIV testing? | ||
| Do you help people with housing issues? | ||
| Do you provide or produce any information resources about HIV/AIDS? | ||
| Does your organisation provide accredited legal assistance? | ||
| Do you produce or commission campaigns designed to reach a mass audience? | ||
| Do you provide services for people with mental health problems? | ||
| Do offer a needle exchange service? | ||
| Do you provide any service outside of normal office hours? | ||
| Do you provide palliative care? | ||
| Do you provide community-based, professional or peer-to-peer education, contact or support? | ||
| Does your organisation have services that focus on preventing mother-to-child transmission? | ||
| Do you provide post-exposure prophylaxis (PEP) for people who have been exposed to HIV? | ||
| Do you conduct publicly available research or publish research? | ||
| Do you provide services for people in the immigration process that have no access to publicly funded services? | ||
| Do you provide any support groups (including peer support groups)? | ||
| Do you provide any tuberculosis services? | ||
| Do you provide training or education to professionals, individuals and groups on HIV or related topics | ||
| Do you provide information about treatment of HIV/AIDS? | ||
| Do you provide a service where users don’t need a prearranged appointment? | ||
| Do you provide resources on the web? |
Thank you for taking the time to fill this form: Please return it to paul@nam.org.uk or Paul Adlam, NAM, 77a Tradescant Road, London, SW8 1XJ