Community Resource List Addition

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 freePay what you canSliding scale based on incomeThere is a set price, but it can be waivedInsurance acceptedMedicare acceptedMedicaid acceptedMust pay full priceAnother option:
Do you have a physical location?*

Yes, open to the publicYes, but it's just an admin office closed to the publicNo
Hours you are open to the public
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your restroom situation?

No public restroomsRestrooms are not genderedMen's, Women's, and a non-gendered option such as a Family RestroomMen's and Women's only, individuals may use whichever they preferMen'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?*

YesNo
Which gender groups do you use?

Men's and Women's onlyMen's, Women's, and a non-gendered or coed optionAnother system:
How are clients assigned to gendered groups?

Sex listed on birth certificateSex listed on driver's licenseAppearanceGender the client says they areClients are not assigned, they may simply show up to whichever group they chooseAnother system:
Is a passport an acceptable substitute?

YesNo
Can clients choose to be in a different gender group?

NoYes, if the client requests a changeYes, all clients are explicitly offered the choice of groupAnother system:
Do people fill out any paperwork or complete an intake interview or questionnaire to join, receive services, or become involved in your organization?*

YesNoOnly for certain things:
Can a person change their name in your records?

NoYes, requires legal name change documentationYes, without a legal name change
Does your intake form, interview, or questionnaire ask potential clients or participants about their sex and/or gender?

YesNo
How is this worded?
What answer choices are available?

None, it's just a blank where they can write in anything they wantThese 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?

NoYes, requires surgeryYes, requires changed legal document(s)Yes, all they have to do is askAnother system:
Does your intake form, interview, or questionnaire ask potential clients or participants about their pronouns?

YesNo
How is this question worded?
What answer choices are available?

None, it's just a blank where they can write in anything they wantThese 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?

YesNo
How is this question worded?
What answer choices are available?

None, it's just a blank where they can write in anything they wantThese 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?

YesNo
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?
Should be Empty: