Ohio LGBTQ+ Provider Guide - Entry Form

Thank you for your interest in our Ohio LGBTQ+ Provider Guide. Your answers will help us best connect members of the LGBTQ+ community to your services.

Please note: You must answer "yes" to at least one of the questions marked with (!) in order to be eligible for a listing in the guide. These answers are self-reported.

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* Name

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* Please provide us with your organization/practice address. Your email is for internal use only and will not be published.

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* If you currently work for Equitas Health, please provide the name of the location(s) at which you work.

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* What kind of medical or social services do you offer?

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* Does your practice/organization have a website? If so, please link to it here.

Reminder:
You must answer "yes" to at least one of the questions marked with (!) in order to be eligible for a listing in the guide. These answers are self-reported.

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* (!) Have you received any LGBTQ+ -specific Cultural Competency training?

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* (!) Does your paperwork provide space for clients to
  • Indicate their relationship status as partnered
  • Differentiate between their sex and gender
  • Indicate preferred name and pronouns?
  • or have an alternate method of allowing clients to record this information?

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* (!) Does your practice/organization have any visible or available educational/supportive materials printed specifically for the LGBTQ+ community?

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* (!) Does your organization or practice provide any services specific to the transgender community?

(Services may include: Hormone Replacement Therapy (HRT), Therapist letters for gender-affirming treatment, gender-affirming surgeries, gender-affirming therapy, gender-affirming surgery, inclusive support groups or programs, etc.)

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* Do you provide any Telehealth Services?

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* If you provide Telehealth services, are they temporary (for COVID-19), or ongoing?

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* Are there other providers or organizations in OH that you think we should contact regarding excellent LGBTQ+ care?

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* May we contact you about potential training opportunities with the Equitas Health Institute?

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