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.
Name
Your answer
Email
Your answer
Provider Information
Provider Name
Formatting: First Name, Last Name, Titles (ex. Jane Smith, LCSW) **If you only have an organization name, please put that in this box**
Your answer
Organization Name
Formatting: Organization Name (ex. Sage Community Health Collective) **If you only have an organization name, please put that name in the "Provider Name" box**
Your answer
NPI #
You can find your NPI number here: http://npidb.org/npi-lookup/ . If you can't find it or don't have the time to look it up, please don't worry about it.
Your answer
Description of Organization or Provider Services
Please provide a brief description of your organization or your theory of care. This could be a mission statement or similar. If the answer to this question is not obvious to you, please leave it blank.
Your answer
Street Address
Formatting: Street #, Street Suite # (ex. 5555 N. Main St, #2)
Your answer
City
Your answer
State
Your answer
ZIP Code
Your answer
Country
Phone Number
Formatting: (555) 555-5555
Your answer
Fax Number
Formatting: (555) 555-5555
Your answer
Other Practice Locations
If you have multiple practice locations, please put in the other addresses and contact numbers below. **Multiple locations can be separated with a semi-colon (;)**
Your answer
Email
Your answer
Website
If available.
Your answer
Office Hours
Specific Formatting: Days: Mon, Tues, Wed, Thurs, Fri, Sat, Sun; Hours: 9 am – 4:30 pm; Extra Specifics: (Walk-ins, Appt Only, New Patients) ***(Long Formatting Example: Mon, Tues, Wed - 9 am – 4:30 pm (By Appointment Only); Thurs-Sat – 10:30 am – 7 pm (Appointments and Walk-ins); Sun – Closed)***
Your answer
Office Hours at Other Locations
If this is applicable, please use the formatting above and preface the different hours with each new location.
Your answer
Additional Languages Spoken
Check or list (in the "Other" box) as many languages that are applicable. If listing multiple languages in the "Other" box, please separate them with a semi-colon (;)
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