Provider Self-Input Form

Thank you for your interest in being a part of RAD and your commitment to providing safe and affirming care to the trans, gender non-conforming, intersex, and queer communities!

While we are committed to including providers from a wide range of care professions, many of the questions are specifically aimed at health care providers. If any of the questions on this form are not applicable, please skip them.

We've designed this questionnaire to give us an in-depth understanding of your services, but the form should take no more than 15-20 minutes for you to complete. Many of the questions are designed to give us an understanding of your provider services or organization. We've also included questions that give you the opportunity to introduce yourself to trans, gender non-conforming, intersex, and queer communities. Your answers to these questions will make community members feel more comfortable seeking your care. We encourage you to be as in-depth as possible in your response to these questions. If very little information is included, we may not feel comfortable adding you to RAD.

If you need any help, clarity, or guidance, please contact info@radremedy.org for assistance.

    Person Submitting This Form

    Providers and their staff may submit this form. If the name and/or contact information for the person entering this information is different that the provider themself, please list that here.
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    Provider Information

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