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.
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Email *
Name *
Phone Number
Is it okay to contact you? *
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) *
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? *
Are you interested in sharing your story on one of our platforms?  If yes, we will contact you to discuss first. *
Have you attended one of our virtual or in-person events before? *
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This form was created inside of Conversion Therapy Dropout Network. Report Abuse