Client Intake Form

Ethnicity *

Hispanic - subgroup *

Race

Asian - subgroup

Native Hawaiian/Pac. Islander – subgroup

Checkboxes

Current gender identity *

You selected "other" for current gender identity, would you like to specify?

If you would not like to specify, skip this question

What pronouns do you prefer?

Pronouns are things like he/him, she/her, they/their, mx, ze or others as you'd prefer

Sexual Orientation (check only one please) *

You selected "other" for sexual orientation, would you like to explain further?

This question is optional

Marital status *

Education level

Do you have insurance?

You said you do not have health insurance. Would you like assistance in applying for insurance?

Type of Insurance: *

Household income: Please identify your annual household income using the check boxes provided *

Household size: (Please include members of your permanent household only) *

How did you hear about LGBT Life Center and our services (check all that apply): *

You selected "online/social media" for how you heard about us. Can you tell use which service you heard about us on?

Examples would include: Facebook, Instagram, Twitter, Pandora Radio, Grindr, Scruff, Jack'd, Google search, or another website

You selected "billboards/public transit" for how you heard about us. Can you tell us where?

Examples would include: Hampton Roads Transit, a billboard on Military Highway, etc.

Are you interested in notifications from us regarding future events, and/or other important information? *

How do you prefer to receive this information?