Client Intake Form
Tell us about yourself!
Preferred Name
*
First Name
Last Name
Pronouns
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you identify as a sexual or emotional minority? (i.e. gay, lesbian, bi, etc.)
Yes
No
Please share your sexual orientation below.
*
Are you transgender, genderqueer, nonbinary, or gender expansive?
*
Yes
No
Please share your gender identity below.
*
Which group(s) do you attend? Select all that apply.
*
Youth Group (13-17)
Youth Group Jr (9-13)
Young Adult Group (18-26)
Worth the Wait (18+)
Aging With Pride (55+)
TransFamily (Parents of Transgender Youth)
Transgender and Gender Non-Conforming Group (18+)
HIV+ Support Group (18+)
Adult LGBTQ+ Dungeons and Dragons (18+)
Youth LGBTQ+ Dungeons and Dragons (Under 18)
Queer Peers (26+)
None of the Above
Which group(s) are you interested in attending? Select all that apply.
*
Youth Group (13-17)
Youth Group Jr (9-13)
Young Adult Group (18-26)
Worth the Wait (18+)
Aging With Pride (55+)
TransFamily (Parents of Transgender Youth)
Transgender and Gender Non-Conforming Group (18+)
HIV+ Support Group (18+)
Adult LGBTQ+ Dungeons and Dragons (18+)
Youth LGBTQ+ Dungeons and Dragons (Under 18)
Queer Peers (26+)
None of the Above
Do you have any medical needs or accessibility needs?
Are you experiencing any major crises? (Select all that apply)
*
Mental or Physical Illness
Housing
Food/Water Accessibility
Abuse or Violence
Discrimination
Unemployment
Poverty
None of the above
Other
Are you seeking assistance with any of the above issues?
*
Yes
No
Anything else you need The Frederick Center to know?
How did you hear about The Frederick Center?
*
Please Select
Friend/Family
Web Search
Event
Referral
Other
Submit
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