Application to be included as a medical or behavorial resource for
This application will determine if your practice is inclusive of the LGBTQ+ Community and is a safe spot for those to get appropriate care with no discrimination. Please answer each question and I will get back to you as soon as possible. If determined to be included, there will be an asterisk which will state as being newly added through a vetting process.
Email address *
Name and specialty *
Your answer
Where is your practice located? *
Your answer
Contact info of practice *
Your answer
Website if any
Your answer
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This form was created inside of Messias Pedro.