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Just The Pill

JTP Clinic Outpost Interest Form

Please complete this form thoroughly to help us proceed together. A staff member will follow up with you. THANKS!

First Name *

Last Name *

Email *

Organization/Congregation Name *

Street Address *

Website *

Social media handles *

Please describe the size and makeup of your regular group participants. *

Please list all recurring activities at your facility as well as dates, times, and group sizes. This could include weekly worship meetings, study groups, childcare services, community support, or mutual aid projects. *

What makes your group a great fit for the JTP Clinic Outpost program?

Select all that apply to your facility *

Private parking lot connects to building

ADA accessible building

Fenced in lot (chain link)

Fenced in lot (privacy fence)

Security cameras on site

Parking garage or shelter (detached)

Other (describe below)

Please share additional info about parking, or exterior building access here.

Do you understand that JTP Clinic Outpost activities are considered Need to Know only, and JTP will provide training on how to discuss and offer Outpost support in ways that preserve privacy and safety for everyone involved? This means that an entire congregation/membership should not be aware of when Outpost services are being provided, or to whom. JTP will ask Outpost volunteers to enter confidentiality agreements upon training completion. *

Yes