Request Advocacy
After you fill out this form an advocate will contact you within 24 hours to discuss your needs. *If you are in an emergency situation please call 911 and if you need an advocate to meet you at the hospital call or text: 502-694-2227 and we will do our absolute best to accommodate*

If you need financial assistance fill out this form: https://goo.gl/forms/KDlge65cVENjUqOq2

Name *
Your answer
What Pronouns Do You Use? (If you prefer to just be addressed by your name, just write that in this blank) *
Your answer
Email
Your answer
Phone number
Your answer
Preferred Way of Contact *
Zip Code *
Your answer
Type of Appointment (Transition Related, Surgery, Primary Care, Etc.) *
Your answer
Date of Appointment
MM
/
DD
/
YYYY
Time of Appointment
Time
:
Anything You Are Particularly Concerned About/Think We Should Know? (This is where you can request an advocate that shares a certain identity with you (trans, fat, PoC, non-male, etc.) if you wish. Here you can also include what language you speak, if it's not english.
Your answer
Submit
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