LGBTQ+ Additional Registration Form
CONTACT INFORMATION
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
GENDER PRONOUNS, IDENTITY & EXPRESSION
GENDER PRONOUNS (click all that apply)
She / Her / Hers
He / Him / His
They / Them / Theirs
Ze / Hir / Hirs
Other (specify below)
Please provide any other pronouns not listed above
I IDENTIFY MY GENDER AS... (click all that apply)
Female / Feminine / Woman
Male / Masculine / Man
Gender Non-conforming
Trans / Transgender
Transsexual
Bigender
MTF / Transgender Man
FTM / Transgender Woman
Two spirit
Intersex
Genderqueer
Genderfluid
Butch
Femme
Questioning
Other (specify below)
Please provide any other gender not listed above
MY GENDER EXPRESSION IS (click all that apply)
She / Her / Hers
He / Him / His
They / Them / Theirs
Ze / Hir / Hirs
Other (specify below)
Please provide any other gender expression not listed above
SEXUAL ORIENTATION
I IDENTIFY MY SEXUAL ORIENTATION AS... (click all that apply)
Female / Feminine / Woman
Male / Masculine / Man
Gender Non-conforming
Trans / Transgender
Transsexual
Bigender
MTF / Transgender Man
FTM / Transgender Woman
Two spirit
Intersex
Genderqueer
Genderfluid
Butch
Femme
Questioning
Other (specify below)
Please provide any other sexual orientation not listed above
MEDICAL
Please list current medications.
Rows
Name
Dosage
Frequency
Pupose
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Please provide your history and insight to your mental health experience including provider names and locations.
What sex did your doctor put on your birth certificate?
Have you ever received hormone treatments? If yes dates, purpose, outcomes?
Have you had any surgeries? If yes dates, purpose, outcomes?
Additional information we should know.
Submit
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