Colorado Springs LGBTQIA2+ Community Support Survey

Inside Out Youth Services, One Colorado, GLAAD and Community Health Partnership are working to coordinate resources available to those impacted by this weekend's attack at Club Q. We are so appreciative of every individual and organization who reaches out to offer services and support, and are working to track, organize and reach out to every inquiry.

We ask that you provide your information in the form below, so that we may reach out to you as our response evolves.

Financial contributions can be made to the Colorado Healing Fund.

If you have any questions or have difficulty completing this form, please contact Rachel Keener (she/her), LGBTQIA2+ Health Equity Manager, at rachel.keener@ppchp.org.

1.Primary Contact:(Required.)

Name & Pronouns

Organization / Company (if applicable)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

2.Secondary Contact:

Name & Pronouns

Organization/Company (if applicable)

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

3.Type of service(s) offered: (select all that apply)(Required.)

Counseling / Mental Health Support

Safe Spaces / Support Groups

Donated Items

Other (please specify)

4.Are there any requirements or fees associated with receiving this service?

Yes

I'm not sure

5.How do people in need access your resources / services? (Location, who to contact, availability, etc.)(Required.)

6.Is there anything else we should know?(Required.)