Report Conversion Therapy
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.
* Required
Email
*
Your email
Name
*
Your answer
Phone Number
Your answer
Is it okay to contact you?
*
Yes
No
Yes, but use discretion.
Required
Location of experience.
*
Your answer
Name of conversion therapy provider or organization.
*
Your answer
Their website, if known.
Your answer
Did you attend?
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Yes
No
How long have you or another person attended?
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Your answer
Please, give as much detail about your experience as possible.
*
Your answer
Has this experience negatively impacted your life in anyway?
*
Yes
No
Maybe
Send me a copy of my responses.
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