SisTers PGH Service Request Form

Please be advised these services are for the Transgender/Non-binary community of Allegheny County - All service requests for our trans and nonbinary community members will be answered within 48 hours.

If you are a Transgender/Non-binary resident of Philadelphia County and are looking for services please visit SisTers PHL to be connected to the SisTers PHL Coordinator.

If you are requesting SisTers PGH Rent Support/Utility Assistance please visit SisTers PGH Rent Request Form.

If you're in need of Transitional Housing Services and are a Black Trans Women in Pittsburgh/Allegheny County please visit, Project T to be connected to our Project T Coordinator.

If youre looking for long-term affordable housing at Monica Roberts Place visit MRP to be connected to our MRP Coordinator.

If you're looking for FREE Mental Health services at SisTers PGH please visit Sisters PGH Therapy Services
Today's Date*

MonthDayYear
Hour MinutesAM/PM Option
Have you received support from Sisters PGH before?

YesNo
1. Client Demographics
What is your full preferred name*
What are your pronouns
(Short answer: e.g., she/her, they/them)
How do you identify in terms of gender? (Select all that apply)*

Trans WomanTrans ManNon-BinaryTwo-SpiritGender non conformingPrefer not to sayOther (please specify)
What is your racial/ethnic identity? (Select all that apply)*

Black or African AmericanLatine/LatinxIndigenous (Native American or First Nations)Asian American and Pacific Islander (AAPI)Southwest Asian and North African (SWANA)WhiteMultiracialOther
Age?
Email (We will initially contact you through phone or email)*
Phone Number?
Address (If Applicable)
Current City
Only Trans residents of Pittsburgh & Allegheny County are eligible for service request services through this form.
Zip Code
What is your current living situation?

Unhoused (shelter, street, car)Staying with friends/family (couch surfing)Transitional housingRenting or owning stable housingOther (please explain)
Do you have dependents living with you?

YesNo
How did you hear about SisTers PGH?*

From one of SisTers PGH social media pages (Sisterspgh on Instagram, facebook, or TikTok)Word of Mouth from a Friend, Relative, or NeighborUnited Way 2-1-1UMPC Medical Center or HosptialAllies for Health and WellbeingAllegheny LinkThrough an information Table at Peoples Pride or another eventOther
Are you currently Employed?*

YesNo
If yes, were do you work?
Hourly Wage/Salary/Sex Work Income Per week?*
How many hours are you eligible to work during each pay period?*
If unemployed, are you looking for employment?*

YesNo
Are You Eligible/Receiving Governmental Assistance? If so please check all that apply. (If you need help getting registered for any government assistance programs please let your intake coordinator know during your first call)

Food Stamps/Cash AssistanceSSI/SSDIWicCAP/LIHEAPMedicaid
How much Governmental/Financial Assistance do you receive in total per month?*
What resources and/or recreational activities are you looking for at SisTers PGH? Select all that apply!*

Marsha's Closet/ClothingProfessional ClothingFood Pantry AccessEmployment NavigationToiletries (Toothpaste, Toilet Paper, Soap etc)Emergency ShelterDropping in at The Stonewall Inn PGH (Sylvia’s Library, peer navigation, computer lab, or safe hang-out space)Transportation Support (Bus pass)Other (Please explain)Covid-19 Rapid TestsN95 Masks
Please give us insight into how these services will help you.*
Employment Navigation
1. If in need of employement, what kind of employment are you looking for?
2. Do you need help with resume preparation, interview skills, or job search?

YesNo
Medical Referrals
If in need of a medical referral, what type of support are you looking for? (Select all that apply)

Primary care servicesHormone Replacement Therapy (HRT)Referrals to specialized providers
Confidentiality Agreement

Please read and sign below
All information shared in this application shall remain confidential and only shared with SisTers PGH leadership and caseworkers to better service you. If you wish to be referred to service providers outside of SisTers PGH you will be ask to complete an authorization form authorizing SisTers PGH to share your information with a 3rd party service provider. SisTers PGH will respond as soon as able to each request.
Print Name Here
Do you consent to your data being used anonymously for reporting and improving services?

YesNo
Signature
Should be Empty:

1. Client Demographics

Employment Navigation

Medical Referrals

Confidentiality Agreement