LGBTQ Patient Intake Form

First Name (this is the name you would like us to call you)

Middle Initial

Last Name

Date of Birth

Address

Address 2

City

State

ZIP Code

Phone Number

Email Address

May we leave a detailed message?

Yes

How do you prefer to be contacted?

Phone

Primary Insurance

Other Insurance

What type of services are you interested in? (Select all that apply.)

Please provide your pronouns.

Please provide us with your gender identity

What is your sexual orientation?

Gay

Lesbian

Heterosexual

Queer

Not sure

Prefer not to say

Other…

I am a:

Privacy and Communication Preferences (for example, Please use this name when you call me.)

Is there any other information that would be important for us to know before contacting you?