Community Resource List Addition
Use this form to suggest your agency for our Community Resource List. This information will be available to the public on our website.
Organization Name
*
Organization Website
Organization Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Email address
example@example.com
What does your organization do?
*
Are your services geared toward any specific populations or people who are in a certain situation? Please describe.
This includes if there is a specific age range to qualify for your services.
What is your organization's philosophy toward the LGBTQAI+ community?
*
L=Lesbian, G=Gay, B=Bisexual, T=Transgender, Q=Queer, A=Asexual, I=Intersex
Is it your organization's belief that any part of being LGBTQAI+ is a sin in any way? Please describe.
*
If a potential client or participant disclosed that they were LGBTQAI+, how would your staff respond?
*
If a potential client or participant disclosed that they were a sex worker, how would your staff respond?
*
If a potential client or participant disclosed that they were living with HIV/AIDS, how would your staff respond?
*
Do you charge money for your services or activities? If so, what are the payment options?
No, everything we do is free
Pay what you can
Sliding scale based on income
There is a set price, but it can be waived
Insurance accepted
Medicare accepted
Medicaid accepted
Must pay full price
Another option:
Do you have a physical location?
*
Yes, open to the public
Yes, but it's just an admin office closed to the public
No
Hours you are open to the public
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your restroom situation?
No public restrooms
Restrooms are not gendered
Men's, Women's, and a non-gendered option such as a Family Restroom
Men's and Women's only, individuals may use whichever they prefer
Men's and Women's only, with these rules about who can use which one:
Do your services or activities involve gendered groups, gendered housing/accommodations, or other placements based on gender?
*
Yes
No
Which gender groups do you use?
Men's and Women's only
Men's, Women's, and a non-gendered or coed option
Another system:
How are clients assigned to gendered groups?
Sex listed on birth certificate
Sex listed on driver's license
Appearance
Gender the client says they are
Clients are not assigned, they may simply show up to whichever group they choose
Another system:
Is a passport an acceptable substitute?
Yes
No
Can clients choose to be in a different gender group?
No
Yes, if the client requests a change
Yes, all clients are explicitly offered the choice of group
Another system:
Do people fill out any paperwork or complete an intake interview or questionnaire to join, receive services, or become involved in your organization?
*
Yes
No
Only for certain things:
Can a person change their name in your records?
No
Yes, requires legal name change documentation
Yes, without a legal name change
Does your intake form, interview, or questionnaire ask potential clients or participants about their sex and/or gender?
Yes
No
How is this worded?
What answer choices are available?
None, it's just a blank where they can write in anything they want
These are the options they have to choose from:
How is this information stored and who has access to it?
Would a child's parents see what they've told you? Can the child choose to keep it confidential?
How does your organization use this information?
Can a person change their gender marker in your records?
No
Yes, requires surgery
Yes, requires changed legal document(s)
Yes, all they have to do is ask
Another system:
Does your intake form, interview, or questionnaire ask potential clients or participants about their pronouns?
Yes
No
How is this question worded?
What answer choices are available?
None, it's just a blank where they can write in anything they want
These are the options they have to choose from:
How is this information stored and who has access to it?
Would a child's parents see what they've told you? Can the child choose to keep it confidential?
How is this information shared with the representatives who will be interacting with them?
Does your intake form, interview, or questionnaire ask potential clients or participants about their sexuality or sexual orientation?
Yes
No
How is this question worded?
What answer choices are available?
None, it's just a blank where they can write in anything they want
These are the options they have to choose from:
How is this information stored and who has access to it?
Would a child's parents see what they've told you? Can the child choose to keep it confidential?
How does your organization use this information?
Does your intake form, interview, or questionnaire ask potential clients or participants about their citizenship status?
Yes
No
How is this question worded?
How is this information stored and who has access to it?
How does your organization use this information?
Any additional notes, clarifications, or info for our resource list?
Submit
Should be Empty: