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LGBT Life Center
Empowering the LGBTQ and HIV communities since 1989.
Call Us
(757) 640-0929
Email Us
info@lgbtlifecenter.org
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Client Intake Form
Client Intake Form
Please enable JavaScript in your browser to complete this form.
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Step
1
of 2
Legal name
*
First
Last
Preferred name
*
First
Last
Preferred language
*
English
Spanish
Other
You selected "other" as your preferred language. Please tell us which language you prefer:
*
Will will do our best to communicate in your preferred language whenever possible.
Date of birth
*
Current age
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing address is different from above
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What's your housing status?
*
Stable/permanent
Temporary
Unstable
Phone
Phone type
*
Cell
Landline
Email
Preferred way of being contacted
*
Phone
Text
Email
Next
Ethnicity
*
Hispanic
Not Hispanic
Don't know
Hispanic - subgroup
*
Puerto Rican
Cuban
Mexican/Mexican, American/Chicano/a
Other origin
Race
Am. Ind/AK Native
Black/African Am.
White
Asian
Native Hawaiian/Pac. Islander
Asian - subgroup
Asian Indian
Chinese
Japanese
Korean
Vietnamese
Filipino
Other Asian
Native Hawaiian/Pac. Islander – subgroup
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Checkboxes
First Choice
Second Choice
Third Choice
Current gender identity
*
Male
Female
Trans female
Trans male
Gender non-conforming/Non–binary
Prefer not to say
Other
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)
*
Gay
Lesbian
Heterosexual
Bisexual
Asexual
Pansexual
Queer
Decline
Other
You selected "other" for sexual orientation, would you like to explain further?
This question is optional
Marital status
*
Married
Single
Divorced
Partnered, not married
Widowed
Decline
Education level
Some high school
Finished High School/GED
Some college, no degree
Degree
Do you have insurance?
Yes
No
You said you do not have health insurance. Would you like assistance in applying for insurance?
Yes
No
Type of Insurance:
*
Private – Employer
Private – Individual
Medicare
VA, Tricare or Military Health Care
Indian Health Service (HIS)
Parent’s insurance
Other plan
Household income: Please identify your annual household income using the check boxes provided
*
$0
$1-$10,000
$10,001- $20,000
$20,001- $30,000
$30,001-$40,0000
$40,001-$50,000
$50,001- $60,000
$60,000+
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):
*
Word of mouth
Online/Social media
Billboards/Public transit
Presentation/Employee
Referral
Other
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?
*
Yes
No
How do you prefer to receive this information?
Email
Mail
Website
Submit
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