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SisTers Service Request Form
Please be advised these services are for the Transgender community of Allegheny County - All service request for our trans and nonbinary community members will be answered within 48 hours. Additionally if you are a
Trans or nonbinary BIPOC experiencing homelessness or housing insecurities you can also apply to our Project T program through the website. Thank you
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Today's
Date
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MM
/
DD
/
YYYY
Email (We will initially contact you through email, and request any documentation pertaining to a financial need if there is one, e.g eviction, shut-off notice, late bills, medical invoices etc, etc..)
*
Your answer
Preferred Name
*
Your answer
Legal Name
Your answer
Pronouns
*
Your answer
Phone Number
Your answer
City
Your answer
Zip Code
Your answer
Address (If Applicable)
Your answer
Gender Identity
Transwoman
Transman
Nonbinary
Other:
Race/Ethnicity
African American
White
Asian
Pacific Islander
Hispanic/LatinX
Other:
HIV Status
Positive
Negative
Other:
Clear selection
Narrative (What brought you here today, please explain in full detail)
Your answer
Are currently Employed?
*
Yes
No
If yes, were do work?
*
Your answer
Hourly Wage/Salary/Sex Work Income Per week?
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Your answer
How many hours are you eligible to work during each pay period?
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Your answer
If unemployed, are you looking for employment?
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Yes
No
Are You Eligible/Receiving Governmental Assistance? If so please check all that apply. (If you need help getting registered for any government assistance programs please let your intake coordinator know during your first call)
*
Food Stamps/Cash Assistance
SSI/SSDI
Wic
CAP/LIHEAP
Medicaid
Other:
Required
How much Governmental/Financial Assistance do you receive in total per month?
*
Your answer
What resources and/or recreational activities are you looking for at SisTers PGH? Please check all that apply!
Clothing
Groceries
Name Change Project: SisTers PGH
GED/Tutoring Support
Employment Navigation
Toiletries (Toothpaste, Toilet Paper, Soap etc)
Emergency Shelter
Medical Services/Mental Health Service Referrals
Dropping in at SisTers PGH too chill in a safe space <3
Transportation Support/Bus Pass/Lyft
Rent/Utility Support (Please be advised our rent/utility support funds are limited priority will be given to trans/nonbinary black and poc siblings))
Please add all additional context explaining these needs. (If requesting financial support please add amount along with additional context)
Your answer
Confidentiality Agreement
All information shared in this application shall remain confidential and only shared with SisTers PGH leadership and caseworkers to better service you. If you wish to be referred to service providers outside of SisTers PGH you will be ask to complete a authorization form authorizing sisTers to share your information with a 3rd party service provider.
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