3 minutes to complete
A person who identifies as LGBTQ+ is eligible to fill the LGBTQ Friendly Intake Form.
Full Name
Age
Date of Birth
Phone Number
Email Address
Home Address
Nationality
How do you identify yourself?
Gender
Do you feel comfortable openly expressing your sexual orientation/gender identity?
Have you ever experienced discrimination or violence because of your sexual orientation/gender identity?
Do you feel like you have to hide your sexual orientation/gender identity in order to avoid discrimination or violence?
Do you feel comfortable discussing your LGBTQIA+ identity with others?
Do you feel that you have a strong support system of family and/or friends when it comes to your LGBTQIA+ identity?
Do you feel that your workplace is LGBTQIA+ friendly?
Do you feel that your community is LGBTQIA+ friendly?
How do you feel to be a part of LGBTQ community?