Report Conversion Therapy

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If you have been subjected to conversion therapy, reparative therapy, aversion therapy, or other sexuality/gender identity change efforts or know someone that has, please, fill out the form below.

All information is kept confidential.

Email *

Name *

Phone Number

Is it okay to contact you? *

Yes

Yes, but use discretion.

Required

Location of experience. *

Name of conversion therapy provider or organization. *

Their website, if known.

May we use this information for our map of CT practices? (Your information will not be shown) *

Yes

How long have you or another person attended? *

Please, give as much detail about your experience as possible. *

Has this experience negatively impacted your life in anyway? *

Yes

Maybe

Are you interested in sharing your story on one of our platforms? If yes, we will contact you to discuss first. *

Yes

Maybe, I need more information.

Have you attended one of our virtual or in-person events before? *

Yes

Send me a copy of my responses.

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