Submit Community Resources
People in the community have suggested opening up the ability to initially submit some of their local community resources they know and trust. This is a simple Google Form that we are initially using to aggregate some of those resources.

- Not all fields are required
- Submitting resources helps us build our list
- Who can submit? Users and Providers
- Why submit? Through our collection process we might initially miss some providers
- If you have more questions, contact info@genderis.com

Once the site eventually launches, there is a more seamless provider registration and user-to-provided submission process.

Provider or Business Name *
Your answer
Address 1 *
Your answer
Address 2
Your answer
Zipcode *
Your answer
Category *
Subcategory *
Website
Your answer
Main Nbr
Your answer
Email
Your answer
Takes Appointments?
Fax
Your answer
Year Established
Your answer
Description
Your answer
Operating Hours
Your answer
Types of Payments Accepted
Insurance Types Taken
Licensed in (State)
Your answer
Licenses Held?
Your answer
Graduated From?
Your answer
Internship done (where?)
Your answer
Practice Areas
Your answer
Age Groups Served?
Your answer
Notes
Your answer
Other Credentials
Your answer
Theoretical Orientation
Your answer
Credential Date
MM
/
DD
/
YYYY
Credentialed Since
MM
/
DD
/
YYYY
Credential #
Your answer
Re-credential Date
MM
/
DD
/
YYYY
Affiliations
Your answer
Degree
Your answer
Submit
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