Healthy Sexuality Programs Interest Form
Thank you for your interest in the Institute on Disabilities healthy sexuality program. We provide sexuality related training and education. Please complete this form so that we can better understand your needs and how we can best support you. If we cannot meet your needs directly, we may be able to connect you with other resources and services. Please note that your responses in this form are only viewed by Healthy Sexuality program staff. You can contact our staff at iodhsp@temple.edu. Your responses are private, but we are mandated reporters, which means that if you share information about an unsafe situation, we may need to share that information with others.
Who is filling out this form?
*
I am completing this form about my own interests or needs.
I am completing this form about my own interests or needs, and someone is helping me.
I am completing this form on behalf of someone else.
Name
*
My First Name
My Last Name
What are your pronouns?
(examples: she/her, he/him, they/them, etc.)
Date of birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How do you like to be contacted?
Telephone call
Email
Video call (Zoom)
When do you like to be contacted?
Morning
Afternoon
Evening
Do you have a legal guardian?
No, I am my own legal guardian
Yes, I have a legal guardian
I don't know
Guardian Name
First Name
Last Name
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email
example@example.com
Tell us more about the person who helped you fill out this form. What is their name?
First Name
Last Name
What is their email?
example@example.com
What is their connection to you?
Your Name
*
First Name
Last Name
What is your organization or agency affiliation, if applicable?
Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your role or connection to the person you are referring?
Parent or guardian
Caregiver
Direct support/service provider
Case manager or supports coordinator
Teacher or educator
Other
Tell us more about the individual you would like to support.
Individual's Name
First Name
Last Name
Individual's Pronouns
(she/her, he/him, they/them, etc.)
Individual's Date of Birth
-
Month
-
Day
Year
Date
Individual's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individual's Email
example@example.com
Individual's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does this person know a referral was made? May we contact them directly?
Back
Next
Tell us more about what you need.
What kind of support are you looking for? Choose all that apply
*
Sex/sexuality education or learning about healthy relationships
Support related to sexual harm (abuse, harassment, assault)
Support with sexuality-based behavioral health needs
Support with legal issues
Request for a specific type of assessment or evaluation
Technical assistance (for example, training for a team or a program consultation)
Other
I am not sure
What is the name or type of assessment or evaluation are you interested in?
As a reminder, this information is only accessed by Institute on Disabilities Healthy Sexuality program staff. If you need a referral to an outside organization, would you like us to share your information with them?
Yes, I give permission for you to share my information for referral purposes
No, please provide me with the contact information and I will refer myself
How did you hear about us?
I worked with the Institute on Disabilities in the past.
I attended a training by the Institute on Disabilities.
I found your information online.
Someone told me about you.
Other
Submit
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