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LGBTQ Friendly Intake Form

This is a LGBTQ friendly intake form that can be used by counselors, therapists, or other mental health professionals when working with LGBTQ clients. The form usually includes questions about the client's identity, pronoun preference, coming out experience, and other relevant information. It is designed to help the provider collect important information about the client in order to provide more culturally competent care.

Time to complete

3 minutes

Eligibility

A person who identifies as LGBTQ+ is eligible to fill the LGBTQ Friendly Intake Form.

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Questions for LGBTQ Friendly Intake Form

1.

Full Name

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Date of Birth

The answer should be a date input.
4.

Phone Number

The answer should be a phone number.
5.

Email Address

The answer should be an email input.
6.

Home Address

The answer should be a text input.
7.

Nationality

The answer should be a country.
8.

How do you identify yourself?

The answer should be a single choice:
  1. Lesbian
  2. Gay
  3. Bisexual
  4. Transgender
9.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Transgender male to female
  4. Transgender female to male
  5. Non Binary
10.

Do you feel comfortable openly expressing your sexual orientation/gender identity?

The answer should be a single choice:
  1. Yes
  2. No
  3. Sometimes
11.

Have you ever experienced discrimination or violence because of your sexual orientation/gender identity?

The answer should be a single choice:
  1. Yes
  2. No
12.

Do you feel like you have to hide your sexual orientation/gender identity in order to avoid discrimination or violence?

The answer should be a single choice:
  1. Yes
  2. No
13.

Do you feel comfortable discussing your LGBTQIA+ identity with others?

The answer should be a single choice:
  1. Yes
  2. No
14.

Do you feel that you have a strong support system of family and/or friends when it comes to your LGBTQIA+ identity?

The answer should be a single choice:
  1. Yes
  2. No
15.

Do you feel that your workplace is LGBTQIA+ friendly?

The answer should be a single choice:
  1. Yes
  2. No
16.

Do you feel that your community is LGBTQIA+ friendly?

The answer should be a single choice:
  1. Yes
  2. No
17.

How do you feel to be a part of LGBTQ community?

The answer should be a rating.

Similar Ideas

  • SafeSpace Intake Form
  • The LGBTQ+ Center Intake Form
  • The Trevor Project Lifeline Intake Form
  • The Rainbow Center Intake Form
  • The Ali Forney Center Intake Form The National LGBTQ Task Force Intake Form The Gay & Lesbian Alliance Against Defamation (GLAAD) Intake Form The National Gay and Lesbian Chamber of Commerce (NGLCC) Intake Form The National Center for Transgender Equality (NCTE) Intake Form

Here are some FAQs and additional information
on
LGBTQ Friendly Intake Form

What is the LGBTQ Friendly Intake Form?

The LGBTQ Friendly Intake Form is a form that allows patients to identify themselves as LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, or any other non-heterosexual orientation or gender identity) so that providers can better understand their needs and provide more culturally competent care.

What is the purpose of the LGBTQ Friendly Intake Form?

The purpose of the LGBTQ Friendly Intake Form is to help connect LGBTQ individuals and families with affirming and inclusive care providers.

What information do I need to provide on the LGBTQ Friendly Intake Form?

The LGBTQ Friendly Intake Form asks for basic information about your identity and your basic details.

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