MILWAUKEE LGBT COMMUNITY CENTER REFERRAL FOR CLINICAL SERVICES

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Legal First Name *

Legal Last Name *

Preferred Name (Name you go by) *

Gender Assigned at Birth *

Male

Female

Intersex

Gender Identity *

Male

Female

Non-Binary

Other:

Pronouns *

Sexual Orientation *

Date of Birth *

YYYY

Age *

Address (including zip code) *

Phone Number *

Email Address *

Preferred Method of Contact *

Phone

Other:

Required

Race/Ethnicity (check all that apply) *

American Indigenous or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Inupiat Traditional Gov't., etc.)

Asian or Asian American (e.g., Chinese, Japanese, Filipino, Korean, South Asian, Vietnamese, etc.)

Black or African American (e.g., Jamaican, Nigerian, Haitian, Ethiopian, etc.)

Hispanic or Latino/a (e.g., Puerto Rican, Mexican, Cuban, Salvadoran, Colombian, etc.)

Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Moroccan, Israeli, Palestinian, etc.)

Native Hawai`ian or Pacific Islander (e.g., Samoan, Guamanian, Chamorro, Tongan, etc.)

White or European (e.g., German, Irish, English, Italian, Polish, French, etc.)

Prefer not to say

Other:

Required

Preferred Method of Services: *

In-Person

Telehealth/Virtual

Doesn't Matter

Referral Source *

Briefly explain the reason for seeking mental health/counseling services (please provide any information that you feel will be helpful): *

General Availability *

Special Accommodations (if needed) *

Are you looking for a letter of support for gender affirming surgery? *

Yes

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