Change of Contact Information
If you are a healthcare provider in New Jersey and are already listed on Garden State Equality's Affirming Healthcare Map but need to change your contact information, please update us by filling out this form. Please fill out the form completely, even the details that are remaining the same, so that we can ensure our data is as accurate as possible.

If you are not yet listed on the map but would like to be, fill out this form instead.
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Are you an individual practitioner or part of a larger group of providers?
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Healthcare Facility/Group Name
Provider Name(s)
Email Address *
For contacting you only - this will not be listed on the map.
Phone Number *
Please enter in the format (xxx) xxx-xxxx.
Website
Please include https:// or http:// at the beginning of the URL.
Street Address
City
What county do you practice in? *
Check all that apply
Required
ZIP Code
What are your specialties? *
Check all that apply
Required
Do you provide services in person, virtually, or both?
What types of insurance do you take?
Have you previously undergone a Garden State Equality training on LGBTQ+ cultural competency in healthcare?
Clear selection
If yes, what year were you trained?
Do you have any questions or comments for Garden State Equality's team?
Submit
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