*New* VDHP Provider Profile
The Vermont Diversity Health Project (VDHP) exists to improve the health and wellness of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) Vermonters by building bridges between healthcare providers and LGBTQ people throughout the state. We help patients identify safe, affirming, supportive, and effective healthcare providers, and offer trainings and other support to enhance providers’ skill in working with LGBTQ people.
In filling out this form, you will be providing information for review prior to integration into the VDHP site.
Provider Name *
Your answer
Provider Gender Identity
Your answer
Provider Sexual Orientation
Your answer
Provider Racial Identity
Your answer
Practice Name *
Your answer
Service Type *
Required
Address Details
Street Address *
Your answer
City *
Your answer
State *
Your answer
ZIP Code *
Your answer
Contact Information
Phone Number: *
Your answer
Email Address: *
Your answer
Website:
Your answer
Facebook:
Your answer
Twitter:
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Instagram:
Your answer
Hours of Operation
Please list your open hours, and input a "C" days closed
MondayHours *
Your answer
TuesdayHours *
Your answer
WednesdayHours *
Your answer
ThursdayHours *
Your answer
FridayHours *
Your answer
SaturdayHours *
Your answer
SundayHours *
Your answer
VDHP Assessment
My practice is committed to providing safe and affirming care to lesbian, gay, bisexual, transgender, queer and questioning individuals *
Our staff has completed LGBTQ Best Practices training *
If yes, what organization provided the training? Date?
Your answer
My non-discrimination policy includes...
My office/space...
My practice currently serves patients/clients who identify as...
Does your practice care for youth patients (22 and under)? *
If yes: when caring for youth patients, my practice...
Specialties
Your answer
Areas of expertise
Your answer
My practice accepts these insurance plans: *
Your answer
I am...
Languages spoken in our practice (besides English):
Your answer
Other information regarding my practice you should know about:
Your answer
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