Empowerment program interest form

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The Empowerment Program provides LGBTQ+ youth (12-20) and allies with skills for creating more inclusive & supportive environments in their schools, families, and communities.

Full name *

Pronouns (he/she/they/other)

Date of Birth *

YYYY

Grade *

School *

Address

City

Zip Code

Phone Number (home/cell?) *

Best day/time to contact

Email *

Are you out to your family/guardians *

yes

Would you be interested in receiving Family Acceptance Support?

yes

Clear selection

Ok to say “Calling from Empowerment program”? *

yes

Current living situation: (Who do you live with? Mom, Dad, Siblings, Grandparents, Foster Parents?)

Emergency contact name

Emergency contact relationship to you

Emergency contact information (phone number):

Healthcare Provider

Name of Social Worker/Therapist

Contact info:

Other groups/services accessed (Sport Teams/Clubs/Church/Youth Groups/Tutoring/Mentorship, etc.)

Current areas of concern:

Substance Use History

Active

Inactive

Clear selection

Suicidality (within 6 months)

yes

Clear selection

Ok to have your picture taken on site or at events? (Pictures may be posted on CHD or RCC website or used in promotional materials)

yes

Clear selection

Age Group

0-15

16-25

25+

Decline to state

Clear selection

Primary Language

English

Spanish

Decline to state

Other:

Clear selection

Race

More than one race

Decline to state

Hispanic or latino/a

American Indian/Alaskan Native

Black/African American

Asian

White/caucasian

Native Hawaiian/Pacific Islander

Other:

Clear selection

Hispanic or Latino/a

yes

Clear selection

If Hispanic or Latino/a

n/a

Caribbean

Central american

Mexican/Mexican American/Chicano

Puerto Rican

South American

Other:

Clear selection

If Non-Hispanic or Non-Latino/a

Not Applicable

African

Asian Indian/South Asian

Cambodian

Chinese

Eastern European

European

Filipino

Japanese

Korean

Middle Eastern

Vietnamese

Other:

Clear selection

Sexual Orientation

Heterosexual/Straight

Gay or Lesbian

Bisexual/Pansexual

Queer

Questioning or unsure of sexual orientation

Decline to state

Other:

Clear selection

Assigned sex at birth

Male

Female

Decline to state

Other:

Clear selection

Current gender identity

Man

Woman

Transgender (man/woman)

Genderqueer

Questioning/unsure of gender identity

Non-binary

Decline to state

Other:

Clear selection

Active Military Status

Yes

Decline to state

Clear selection

Veteran Status

Yes

Decline to state

Clear selection

Disability Status (a disability is a physical or mental impairment or medical condition lasting at least six months that substantially limits a major life activity, which is not the result of a severe mental illness)

Yes

Decline to state

Clear selection

If yes, please describe (check all that apply)

N/a

Difficulty seeing

Difficulty hearing or having speech understood

Physical/mobility

Chronic health condition (including but not limited to chronic pain)

Cognitive disability not including severe mental illness (including but not limited to a learning disability, developmental disability, dementia, traumatic brain injury)

Other:

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