This form is part of Resource Center's Gender-Affirming Health Care program. In an effort to better serve our community, we are asking for your experiences as an LGBTQ individual, and we are gathering these responses in order to be able to provide more comprehensive referrals. 

Referrals can be for any provider or service you feel is relevant to be an LGBTQ-competent provider: medical, cosmetic, legal, mental/behavioral health, support groups, substance use, housing or food support, etc.

You can also submit feedback if you had a negative experience, whether you felt the provider was uneducated, homophobic, transphobic, or if you otherwise had a bad experience.

Please feel free to give as many referrals as you want.

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* 1. What is your age?

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* 2. What is your race? Please select all that apply

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* 3. Are you Hispanic or Latino

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* 4. What is your sexuality? Please select all that apply

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* 5. What is your gender identity? Please select all that apply

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* 6. Please input the contact information for your referral as completely as possible (i.e. name, address or city, phone number, email, website, etc) so that we are able to find them

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* 7. Please describe what services this referral offers

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* 8. Is this a provider/location you would or would NOT recommend

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* 9. Please describe your experience with this provider/ location, what makes them a good or bad referral in your opinion?

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* 10. How did you find this provider/location?

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