Are you a provider who wants to be added to a LGBTQ+ provider referral list?

Thank you for your interest. If you are a business or group looking to be added to a queer-friendly business list, please fill out this form instead.

Referral list you would like to be added to: (required)

Individual therapy

Family therapy

Group therapy

Community organization centering LGBTQ+ communities

Gender affirming medical provider (hormones, puberty blockers, etc)

Gender affirming surgery

Primary Care

Specialty medical provider (please specify below)

Vocal coaching

Dietician

Electrolysis

Summer camp

Faith community

Other (specify below)

If you selected "other," please specify:

About You

Type of practice:(required)

Select one option Individual Group Other

First and Last Name or Group Practice Name(required)

Pronouns

Credentials

Email of person completing this formNot shared on site. (required)

PhoneShared on site. (required)

Website

Town/State(required)

About Your Services

Are you currently taking new clients/patients?(required)

Select one option Yes No Waitlist only

Do you offer services virtually, in person, or both? (required)

Select one option Virtually In person Both

What insurances do you accept?Please enter N/A if not applicable. (required)

Age range/population servedChoose all that apply (required)

Children (<12)

Teenagers (13-18)

Young Adults (18-24)

Adults (24+)

Seniors (65+)

Parents

Families

Couples

Language(s)

Specialty areas (ADHD, anorexia, endometriosis, etc.)

Approach/ Services offered (ex: CBT, massage therapy, surgery types, etc.)

Reason for interest

Which of the following does your practice have?(required)

All forms ask for chosen name and pronouns

All team members are regularly trained about LGBTQ+ inclusivity

Team members have lived experience that informs their work with the LGBTQ+ population

In person office space has gender neutral bathrooms

Other (please specify)

If you selected "other," please specify:

Lastly, please share any other information about you or your practice you feel is relevant, and why you should be added to our referral list. (required)

SUBMIT

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We will contact you if we require any additional information. Thank you!