Discrimination Intake Form
Please use the form below to share your story. We will not share any information without your permission. If you would like to contact a lawyer for help immediately, we have listed some LGBTQ+ friendly attorneys on our Fairness Resource List at Fairness.org/Resources. You may also call our office at (502) 893-0788. Thank you.
Name
E-mail
Phone
Address
City
State
Where did you experience discrimination? (Please include the city where this occurred.)
When did you experience this discrimination? (Dates or approximate time frames.)
What happened?
Did you report this instance of discrimination anywhere besides the Fairness Campaign? If so, where?
May we contact you about this incident?
Clear selection
May we share your story with elected officials who are considering LGBTQ-inclusive discrimination laws?
Clear selection
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This form was created inside of Fairness Campaign.