Patient/Client Information

Intake Form

All Information is confidential and data will be used to access grants to fund the Transgender Health and Wellness Center.

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* 1. Date

Date / Time

Date

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* 2. Legal Name

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* 3. Preferred Name

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* 4. Address

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code *

Country

Email Address *

Phone Number

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* 5. Date of Birth

Date / Time

Date

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* 6. Age

10 or under

16 or under

18 or under

25 or under

25-30

31-40

41-50

51-60

61-70

71 or above

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* 7. Race/Ethnicity (Check all that Apply)

White

Black or African American

Hispanic

Latinx

Asian

Native Hawaiian/ Pacific Islander

Other (please specify)

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* 8. Ethnicity

Hispanic, Latino/a or Spanish Origin

Not of Hispanic, Latino/a or Spanish Origin

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* 9. Religion

Christianity

Islam

Buddhism

Hinduism

Nonreligious (Secular/Agnostic/Atheist)

Primal-indigenous

None of the Above

Other (please specify)

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* 10. Sexual Orientation

Lesbian (woman who is attracted to other women)

Gay (men who are attracted to other men)

Bisexual (attraction to more than one gender)

Heterosexual ("Straight" or a person feels physically and emotionally attracted to people of a gender other than their own)

Asexual (does not experience sexual attraction or desire for sex)

Pansexual (gender doesn't play a role in your sexual attraction)

Polysexual (attracted to different types of genders, but not all genders)

Other

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* 11. What gender do you identify as?

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* 12. What is your gender expression?

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* 13. What is your HIV status?

Negative

Positive

Undisclosed

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* 14. What is your Hepatitis C status?

Negative

Positive

Undisclosed

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* 15. Have you ever thought of or attempted suicide in the past?

Yes

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* 16. Do you smoke cigarettes?

Yes

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* 17. Have you ever smoked cigarettes?

Yes

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* 18. Do you smoke marijuana?

Yes

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* 19. Have you ever smoked marijuana?

Yes

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* 20. What is your annual income?

No income

$9,999 or less

$13,000 or less

$25,000 or less

$35,000 or less

$35,001 or more

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* 21. What is your current housing status?

Live in a stable housing without fear of being evicted

Live in a unstable housing with fear of being evicted

Do not have a functioning home or are currently homeless

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* 22. Please check what services you are seeking at the Transgender Health and Wellness Center.

Referral to medical care

Peer/Emotional Support

Mental Health Services

Support Groups

Clothing

Food

Pet Food

Housing Referral

Services Referral

Suicide Education and Prevention

HIV/HEP C Education and Prevention

Crisis Intervention

Hair Removal

Volunteering

Youth Assistance

Substance Intervention and Recovery

Legal Assistance Referral

Name & Gender Change

Family Support Group

Employment Assistance

Safe Space

Training

Health Care Advocacy

Homeless Intervention

Gender in the Workplace

Policy Review/Recommendations

Resume Help

Mailing Address

Other (please specify)

Patient/Client Information

Intake Form

Question Title

* 1. Date

Question Title

* 2. Legal Name

Question Title

* 3. Preferred Name

Question Title

* 4. Address

Question Title

* 5. Date of Birth

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* 6. Age

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* 7. Race/Ethnicity (Check all that Apply)

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* 8. Ethnicity

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* 9. Religion

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* 10. Sexual Orientation

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* 11. What gender do you identify as?

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* 12. What is your gender expression?

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* 13. What is your HIV status?

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* 14. What is your Hepatitis C status?

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* 15. Have you ever thought of or attempted suicide in the past?

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* 16. Do you smoke cigarettes?

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* 17. Have you ever smoked cigarettes?

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* 18. Do you smoke marijuana?

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* 19. Have you ever smoked marijuana?

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* 20. What is your annual income?

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* 21. What is your current housing status?

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* 22. Please check what services you are seeking at the Transgender Health and Wellness Center.

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* 23. What is your email address?