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Youth & Young Adult Intake Form
Please fill out this form with your information. This information is confidential and will not be shared with anyone.
Youth 12-17
Young Adult 17-24
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* Required
First Name (the name you prefer to go by)
*
Your answer
Last Name
*
Your answer
Pronouns
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Age
*
Your answer
Current Discord name
*
Your answer
Your Contact Phone Number
*
Your answer
Email Address
*
Your answer
Zip Code
*
Your answer
State
*
Your answer
Race/Ethnicity
*
Black or African American
American Indian or Alaska Native
Latinx/Chicano/Chicana/Chicanx
Middle Eastern
Pacific Islander or Native Hawaiian
White
South Asian
Southeast Asian
Asian or Asian American
Other:
Required
Gender Identity
*
Transgender
FTM/Trans man
MFT/Trans woman
Nonbinary
Two Spirit
Cisgender
Other:
Required
Sexual Orientation
*
Queer
Bisexual
Lesbian
Gay
Asexual
Other:
TQYC programs you are interested in
*
Monday DND group
Tuesday Minecraft group
Wednesday BIPOC group
Thursday Group
Friday Creative Queers
Youth Discord
Young Adults Discord
Young Adults Group
Peer Advocate/Internship
Affirmative Gender Care
Other:
Required
Resources you already have
*
Counselor/Therapist
Family support
Friend support
Social media/virtual support
School support
Medical support (Gender affirming care)
Other:
Required
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