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. Go backYour message has been sent What type of service do you provide?(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) Warning If you selected “other,” please specify: Warning About You Type of practice:(required) Select one option Individual Group Hospital based practice Other Warning Name of person completing this formNot shared on site. (required) Warning Email of person completing this formNot shared on site. (required) Warning First and Last Name & pronouns/credentials, or Group Practice Name (that you would like listed on the website)(required) Warning Phone for new clients/patientsShared on site. (required) Warning Website Warning City/State of physical location or virtual licensure(required) Warning About Your Services Are you currently taking new clients/patients?(required) Select one option Yes No Waitlist only Warning Do you offer services virtually, in person, or both? (required) Select one option Virtually In person Both Warning What insurances do you accept?Please enter N/A if not applicable. (required) Warning Who can access your services?(required) Children (<12) Teenagers (13-18) Young Adults (18-24) Adults (24+) Seniors (65+) Parents Families Couples Warning Language(s) Warning Specialty areas (ADHD, anorexia, endometriosis, etc.) Warning Approach/Types of services offered (ex: CBT, massage therapy, surgery types, etc.) Warning Reason for interest Choose several options 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) Warning If you selected “other,” please specify: Warning 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) Warning Warning. SUBMITSubmitting form Δ We will contact you if we require any additional information. Thank you!
Queer RI 