Group Registration
Name
*
First Name
Last Name
Affirmed/Preferred Name
First Name
Last Name
My pronouns are:
They/Them
She/Her
He/Him
Other
I would like to meet in person (if available):
Yes
No
Have you been to the Pride Center before?
*
Yes
No
Unsure
Have you been to any of our groups before?
*
Yes
No
Unsure
Have you completed an intake in the past 6 months?
*
Yes
No
Unsure
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Living Situation:
*
Rent (you or household)
Own (you or household)
Homeless
With Relations/Friends
Transitional Housing
Residential
Other
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Residential Details:
Residential - Psychiatric
Residential - Group Home
Residential - Treatment
Other
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Gender Identity:
*
Man/Boy
Woman/Girl
Transgender Man/Boy (F to M)
Transgender Woman/Girl (M to F)
Non-binary
Gender Non-conforming
Not sure/Questioning
Other
Sexual Orientation:
*
Gay
Lesbian
Straight/Heterosexual
Bisexual
Queer
Pansexual
Asexual
Not sure/Questioning
Other
Race:
*
Black/African American
White
Asian
Native American/Alaska Native
Native Hawaiian/Pacific Islander
Other
Ethnicity:
Non-Hispanic
Hispanic
Are you the parent or caregiver of a transgender youth?
Yes
No
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Youth Legal Name
First Name
Last Name
Youth Affirmed/Preferred Name
First Name
Last Name
Youth Date of Birth
-
Month
-
Day
Year
Date
Youth Current Gender Identity:
Man/Boy
Woman/Girl
Transgender Man/Boy (F to M)
Transgender Woman/Girl (M to F)
Non-binary
Gender Non-conforming
Not sure/Questioning
Other
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Next
How did you hear about us?
*
Friend/Family
Social Media/Media/Website
School
Mental Health Service Provider
Department of Social Services
Pride Center Staff
Community Organization
Walk In/Self
Physician
Other
Which group(s) are you interested in? (Please select all that apply)
*
Silver Pride (older LGBTQ+ people)
Soul 2 Soul (LGBTQ+ people of color)
TransGeneration (people of trans experience, nonbinary people, etc.)
Under Construction (people of trans experience, nonbinary people, etc. who are at any stage of coming out or who are questioning their gender identity)
Bi+ Community Meetup
LGBTQ+ Men's Group
Mild to Wild (LGBTQ+ sex and substance use support group)
Transgender and nonbinary youth support group
Support group for parents and caregivers of transgender and nonbinary youth
Femmes & Thems (women of trans experience, cisgender women who are part of the LGBTQ+ community, nonbinary people)
Living the Experience (transgender, nonbinary and gender-nonconforming people from communities of color)
Please select if you would like us to contact you regarding other services:
*
Other Support Groups
Social Events
Counseling/Testing
Staff Training/Education
Workshops
Referrals/Linkages
Other
I will need the following accommodations in order to participate:
*
American Sign Language (ASL) Interpreter
Wheelchair Access
Other
How can we contact you to follow up about groups and other services? (Please select all that apply)
*
Email
Phone Call
Text Message
Other
Submit
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