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Specialty^* (hold down the control key to select multiple specialties)
Acupuncture Allergy/Immunology Alternative & Complementary Therapy Cardiovascular Medicine Chinese Medicine Chiropractic Colorectal Surgery Dentistry Dermatology Emergency Medicine Endocrinology Family Medicine Gastroenterology Genetics Geriatrics Gynecologic Oncology Gynecology/Women's Health Hematology HIV/AIDS Infectious Disease Infertility & Assisted Reproduction Integrated Medicine Internal Medicine Intersex Medicine Massage Therapy Midwifery Neonatology Nephrology Neurology Neuropsychology Nutrition & Diet Obstetrics Occupational Medicine Oncology Ophthalmology Optometry Oral Surgery Orthopaedic Surgery Osteopathy Otolaryngology Pain Management Palliative Care/Hospice Pediatrics Pediatric Oncology Perinatology Physical Medicine & Rehabilitation Plastic Surgery Podiatry Psychiatry Psychiatry (Child/Adolescent) Psychotherapy/Mental Health (Addictions) Psychotherapy/Mental Health (Couples) Psychotherapy/Mental Health (Eating Disorders) Psychotherapy/Mental Health (Family) Psychotherapy/Mental Health (General) Psychotherapy/Mental Health (Grief & Loss) Psychotherapy/Mental Health (Other) Psychotherapy/Mental Health (Trauma) Pulmonary Medicine Radiology Rheumatology Sports Medicine Thoracic & Cardiovascular Surgery Transgender Medicine Travel Medicine Urology

Sub-specialty/Area(s) of expertise: (please list)

Languages spoken by yourself or staff: (please list)

Are you Licensed?^*
Yes No

License Number

License Issuer

License Expiration

Are you Board Certified?^*
Yes No

Certificate Issuer

What health insurance carriers do you accept? (please list)

Hospitals/Institutions you are associated with: (please list)

Do you offer a flexible payment system for patients with no insurance?
Yes No

What percentage of your patients/clients would you say identify as Gay

What percentage of your patients/clients would you say identify as Lesbian

What percentage of your patients/clients would you say identify as Bisexual

What percentage of your patients/clients would you say identify as Heterosexual

What percentage of your patients/clients would you say identify as Transgender

What percentage of your patients/clients would you say identify as Intersex

What percentage of your patients/clients are Caucasian/European

What percentage of your patients/clients are African American

What percentage of your patients/clients are Hispanic/Latino(a)

What percentage of your patients/clients are Asian/Pacific Islander

What percentage of your patients/clients are Native American/Alaska Native

What percentage of your patients/clients are Multiracial

Is your practice Transgender knowledgeable?
Yes No

Is your practice Intersex knowledgeable?
Yes No

Does your agency or practice's intake forms and sexual/social history forms use inclusive language?
Yes No

Does your agency or private practice policies include GLBT patients/clients in their non-discrimination clause? 
Yes No

Would you like to receive GLBT-positive patient materials for your office/agency?
Yes No

Would you or your staff be interested in receiving GLBT-sensitivity training?
Yes No

Gender
Male Female Transgender Intersex

Display Gender in Profile?
Yes No

Ethnicity/Race
Caucasian/European African American Hispanic/Latino(a) Asian/Pacific Islander Native American/Alaska Native Multiracial Other

Display Ethnicity/Race in Profile?
Yes No

Sexual Orientation
Gay/Lesbian Bisexual Heterosexual Other

Display Sexual Orientation in Profile?
Yes No

Additional Info (will display on your profile)

We ask that you satisfy two of the following severn criteria. If you do not, please contact us for examples of language or policies for your practice. Please select any of the following that apply.

	I have documented completion of a GLBTI cultural competency training curriculum, such as The Mautner Project's "Removing the Barriers" program.
	I have conducted medical screenings in the GLBTI community.
	I have conducted documented GLBTI related health research.
	I have volunteered my professional services to a GLBTI organization, such as the Center, Colorado AIDS Project, or Project Angelheart.
	Other:

Finaly, by checking this box, I attest and commit to poviding non-judgmental care of gay, lesbian, bisexual, transgender, intersex and questioning individuals.