Center Registration

The information collected on this form helps us provide you with the most appropriate service(s). To coordinate care, your information may be shared between programs. The information you provide here will be kept confidential, secure and will be shared only within the agency. You may update your information at any time.

Para completar este registro en español: Versión en Español

Вы хотели бы заполнить данный формуляр на русском языке? Русская версия

Are you currently receiving services from the Los Angeles LGBT Center?

Yes

Not sure

Resources and Information

Select all that apply.

Please note that some services have eligibility requirements, and you may not be eligible for all services you are interested in.

I would like resources and information on...(Required)

Trans Support

Health and Wellness

Housing Resources/Support

Mental Health & Social Support

Legal Services

Employment & Education

Basic Needs (e.g., access to food, hygiene products, clothing, etc.)

Community-Based Support

Housing Resources/Support

Housing Referrals/Homeless Prevention Support - Youth (18-24 years old)

Housing Referrals/Support - Seniors (50+ years old)

Community-Based Support

Foster Youth Services

School-Based Support

Mentoring - Youth (18-24 years old)

Community Supports & Events

Mental Health & Social Support

Individual Therapy

Psychiatry

Substance Use and Recovery Services

Support Groups

Employment & Education

Employment Assistance - Trans and Nonbinary

Employment Assistance - Youth (18-24 years old)

Employment Assistance - Seniors (50+)

Education - Youth (18-24 years old)

Legal Services

Name and Gender Marker Change

Immigration Support

Survivor Services (e.g. domestic violence/IPV, sexual assault, hate crimes/incidents, harassment, discrimination, elder abuse, police misconduct, other crime victimization)

Housing Rights (e.g. eviction and landlord issues)

Health and Wellness

Basic Needs (e.g., access to food, hygiene products, clothing, etc.)

Your Information

Name(Required)

First Name Last Name

Legal Name

Legal First Name Legal Last Name

Date of Birth(Required)

Preferred method of communication(Required)

Select all that apply.

Phone call

Email(Required)

Phone Number

Phone Number(Required)

What language would you like to receive services in?(Required)

English

Spanish

Not Listed

If "Not Listed", please tell us your preferred language:

Is it safe to identify ourselves as the Los Angeles LGBT Center when contacting you?(Required)

Yes

Would you like us to still reach out without identifying as the Los Angeles LGBT Center?(Required)

Please reach out to me but do not identify as the Los Angeles LGBT Center.

It’s not safe to reach out to me, I will reach out to you at (323) 993-7400.

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code(Required)

Country

Do you identify as transgender?(Required)

Yes

Prefer not to answer

Do you identify as intersex?

Yes

Prefer not to answer

Gender Identity(Required)

Select all that apply.

Agender

Woman

Man

Genderqueer

Non-binary

Two-Spirit

Questioning

Not Listed, my gender identity is

Prefer not to answer

If "Not Listed", please tell us your Gender Identity:

Pronouns

Select all that apply.

They/them

She/her

He/him

Not Listed

Decline to State

If "Not Listed", please tell us your Pronouns:

Sexual Orientation(Required)

Select all that apply.

If "Not Listed", please tell us your Sexual Orientation:

Ethnicity and Race

Do you identify as American Indian, Indigenous, First Nations or Alaska Native?(Required)

Yes

Not Listed

Prefer not to answer

If "Not Listed", please tell us your Indigenous identification:

What groups do you identify with for your Race and Ethnicity? Select all that apply(Required)

If "Not Listed", please tell us your Race and Ethnicity:

Tells us about yourself.

Is there anything you'd like to share with us to help us better support you? Please avoid including private or sensitive information.

Terms of Service and Privacy Policy

Confirmation of reading Terms of Service(Required)

Click here for the Terms of Service.

I have reviewed and accept the LA LGBT Center’s Terms of Service

Confirmation of reading Privacy Policy(Required)

Click here for the Privacy Policy.

I have reviewed and accept the LA LGBT Center’s Privacy Policy

Comments

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