*New* VDHP Provider Profile
The Vermont Diversity Health Project (VDHP) exists to improve the health and wellness of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) Vermonters by building bridges between healthcare providers and LGBTQ people throughout the state. We help patients identify safe, affirming, supportive, and effective healthcare providers, and offer trainings and other support to enhance providers’ skill in working with LGBTQ people.
In filling out this form, you will be providing information for review prior to integration into the VDHP site.
Email Address *
Your answer
Contact Name *
Your answer
Practice Name *
Your answer
Website (we will use the contact information on your website) *
Your answer
Provider Gender Identity
Your answer
Provider Sexual Orientation
Your answer
Please indicate the category/ies under which you wish to be listed: *
Required
Hours of Operation
Please list your open hours, and input a C for days you are closed / not available
MondayHours
Your answer
TuesdayHours
Your answer
WednesdayHours
Your answer
ThursdayHours
Your answer
FridayHours
Your answer
SaturdayHours
Your answer
SundayHours
Your answer
VDHP Assessment
Do you include a place for patients to indicate their sexual orientation or whom they have sex with (gay, bisexual, MSM, WSW, etc.) when you gather health information on medical forms, during exams, etc.? *
In addition to sex, do you include LGBTQ affirming options for gender identity such as trans, gender non-conforming, agender, etc.? *
Regardless of forms, is it the policy of the facility to routinely ask patients/clients for their chosen name and pronoun? *
Our staff has completed an LGBTQ Best Practices training and / or a training focused on working with the LGBTQ community *
If yes, what organization provided the training? Date?
Your answer
My non-discrimination policy includes...
My office/space...
My practice currently serves patients/clients who identify as...
Does your practice care for youth patients (22 and under)? *
If yes: when caring for youth patients, my practice...
Would you like to list a specialty?
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Would you like to include a personal statement?
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My practice accepts these insurance plans: *
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I am...
Languages spoken in our practice (besides English):
Your answer
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