SisTers PHL Service Request Form
Sisters PHL is a trans-led, trauma-informed, and community-centered organization providing essential resources, housing support, and safe spaces for trans Philadelphians. Our mission is to empower and uplift the trans community by offering drop-in services, advocacy, and long-term housing solutions. Please complete this form in its entirety to be contacted for services.While we do our best to fulfill all requests, services are subject to availability and funding. Completing this form does not guarantee that all requested resources will be provided. Confidentiality & HIPAA ComplianceAll information provided in this form is protected under the Health Insurance Portability and Accountability Act (HIPAA) and will be kept strictly confidential. Sisters PHL will never share your personal data without your consent.
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Year
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Name
First Name
Last Name
Pronouns
Date of Birth
Phone Number
Email
example@example.com
Zip Code
City Of Residence
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Race
Black/African American
Latinx/Hispanic
Indigenous/Native American
White
Asian/Pacific Islander
Middle Eastern/North African
Multiracial
Other
Gender Identity
Trans Woman
Trans Man
Non-binary
Two Spirit
Do you identify with the following?
Disabled
Neurodivergent
Living with HIV
Formerly Incarcerated
Undocumented
Experiencing Homelessness
None of the above
Current Housing Status
Housed (Stabel)
Temporarily Staying with Friends/Family
In Shelter/Emergency Housing
Unhoused (Currently Experiencing Homelessness)
Other
Monthly Income (Including Government Assistance)
No income
Less than $500.00
$500 - $1000
$1000 - $1500
$1500 - $2000
$2000+
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Services Request Type
What resources and/services are you requesting from SisTers PHL? (Select All That Apply)
What services are you requesting from SisTers PHL?
Clothing
Groceries
GED/Tutoring Support
Employment Navigation
Toiletries (Toilet paper, Toothpaste, Soap, etc)
Emergency Shelter
Rent/Utility Support
Medical Services/Mental Health Service Referrals
Dropping in at SisTers PHL (Peer Navigation, Safe Space, Food Pantry, Computer Lab, etc)
Transportation Support (Bus Pass, Lyft)
Other
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Follow-Up Questions Based On Requested Services.
Please provide details to help us serve you better.
Clothing & Toiletries - What specific items do you need?
Groceries - Do you have any dietary restrictions, allergies or cultural/religious food needs?
GED/Tutoring Support - What subjects do you need support in? Are you currently enrolled in any education programs? (Yes/No)
Employment Navigation - What kind of job assistance do you need? (Resume help, job search, interview prep, workplace discrimination support, etc.) Are you currently employed? (Yes/No) What field(s) or industries are you interested in working in?
Emergency Shelter Support - What is your current living situation? (Brief explanation) Do you have any urgent safety concerns? (Yes/No)
Medical/Mental Health Service Referrals - What type of support do you need? (Hormone therapy access, primary care, mental health counseling, substance use support, sexual health services, etc.) Do you have a current healthcare provider? (Yes/No)
HIV Related Services - Do you need support related to HIV services, including healthcare, medications, or peer support? (Yes/No) If Yes, would you like to be connected to HIV-specific resources, such as medical care, PrEP, or support groups? (Yes/No)
Transportation Support - What is your primary transportation need? (e.g., getting to work, medical appointments, housing-related meetings, etc.) What type of transportation support do you need? (Bus pass, Lyft ride, other)
Rent Utility Assistance - What type of assistance do you need? (Rent, electricity, water, etc.) Have you received eviction or utility shutoff notices? (Yes/No) Have you received rental assistance in the past 12 months? (Yes/No)
Please upload Eviction Notice/Utility Shut Offs
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Additional Information - How would you prefer follow up for requested services?
Email
Phone
Text
How did you hear about SisTers PHL?
Social Media
Word Of Mouth
Referral from another organization
Community Event
Other
If referred from another organization, please provide the name of the organization.
Is there anything else you’d like us to know?
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Consent & Submission
By submitting this form, you acknowledge that Sisters PHL will use this information to provide services and resources. All information is protected under HIPAA and will remain strictly confidential.
I confirm that I am a trans individual seeking services from Sisters PHL and agree to the terms and conditions.
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