Center South Client Registration Form

Center Registration

The information collected on this form helps us provide you with the most appropriate services and supports. To coordinate your care, your information may be shared between programs within our agency. All information you provide will be kept confidential and secure and will only be accessed by authorized staff within the agency.

If you have questions, or if you are already registered and need to update your information, please call us at (323) 993‑7400 or email [email protected].

Para completar este registro en español: Versión en Español

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

If you are completing this registration for a minor, please review and confirm the statement below. A minor is anyone who is 17 years old or younger.

I confirm that I am the parent, guardian, or authorized caregiver and have the authority to provide this information for the child listed in this registration.

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

Yes

Not sure

Are you completing this registration at a Center site?(Required)

Yes

Which Center site are you currently visiting?(Required)

Resources and Information

Select all that apply.

Please note: Some services have eligibility requirements, and you may not qualify for every service offered. While many services are available to residents of Los Angeles County and California, a few programs are open to a wider community. These are identified in the services listed below.

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

Trans Support: Trans Support: Choose this option if you would like services that are specifically designed for transgender and nonbinary people. Selecting Trans Support along with another service (e.g., Primary Care or Mental Health) helps us connect you to the most appropriate 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 (includes Social Networking Groups)

Housing Resources/Support

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

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

Community-Based Support

Virtual Groups are open to people from anywhere in the world.

Foster Youth Services

School-Based Support

Mentoring - Youth (12-24 years old)

Community Groups

Community/Social Networking Group

HerStories

Women's Coming Out

HisStories

Zig-Zag Pride

Men's Coming Out

Trans Perceptions

Club Intersex

Trans Gender Diverse or Intersex (TGI) Coming Out

Village Readers

Mental Health & Social Support

Mental Health Services are available to people who live anywhere in California via virtual options.

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)

National DV Hotline 800-799-7233 & Video Phone (only for deaf callers) 1-855-812-1001

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

Note: If it isn’t safe for you to have us identify as the Los Angeles LGBT Center, we can reach out by phone only, without mentioning our agency name. For your safety and privacy, we aren’t able to use email in this situation, since our email address includes the Center’s name.

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.

Do you have a disability or any condition that may require a reasonable accomodation(s)?

Yes

Prefer not to answer

If yes, do you have any of the following?

Mobility Disability (use a wheelchair, walker or have difficulty walking)

Hearing Disability (deaf or hard of hearing)

Visual Disability (blind or low vision)

Cognitive or learning disability (e.g., difficulty with memory, attention, or processing)

Other disability or condition not listed

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code(Required)

Country

Do you identify as intersex?

Yes

Prefer not to answer

Do you identify as transgender?(Required)

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, my pronouns are

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.

Phone

This field is for validation purposes and should be left unchanged.