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Community & Support Groups
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Trans* Lounge Membership
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Center South Behavioral Agreement
Mi Centro Client Registration Form
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Trans Wellness Center Registration
Behavioral Agreement
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Mi Centro Client Registration Form
Community Programs Registration
Enrollment Date
At what location are you registering? / En cual centro comunitario se está registrando?
*
Mi Centro
Center South
I would like resources and information on
- select I would like resources and information on -
Clothing Closet / Armario de ropa
Primary Care/Hormones (HRT) / Terapia de reemplazamiento de hormonas (HRT)
HIV/STD Testing / Detección del VIH/ETS
PrEP / VIH prevención
Employment Resources / Habilidades de trabajo
Name & Gender Marker Change / Cambio nombre y género
Computer Lab / Laboratorio de computación
Mental Health/Therapy / Salud mental/Asesoramiento
Support Groups / Grupos de apoyo
Legal Services / Servicio legal
Housing Resources / Recursos de vivienda
TransAction
Other / Otra
Insurance/Benefits Enrollment
Trans Family Support Group
If other resources and information, please specify
First Name / Nombre
*
Last Name / Apellido
*
Gender / Género
*
Woman / Mujer
Man / Hombre
Transgender Woman / Mujer Transgénero
Transgender Man / Hombre Transgénero
Non-Binary / No Binario
GNC / Género No Conforme
2-Spirit / Dos Espirítu
Intersex (AFAB) / Intersexual (Mujer asignada al nacer)
Intersex (AMAB) / Intersexual (Hombre asignada al nacer)
Declined to ID / Declina
Other / Otra
If other gender, please specify / Si identificas de otro género, por favor explicanos
Pronouns / Pronombres
- select Pronouns / Pronombres -
She/Her - Ella
He/Him - El
They/Them - Ellos, Usted,Vos
She/They - Ella/Ellos
He/They - El/Ellos
Zie/Zir
Other - Orta
Birth Date / Fecha De Nacimiento
*
Race / Raza
*
- select Race / Raza -
African-American/Black
Asian/Asian American
Bi-racial/Multi Racial
Latino/Hispanic
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White/Caucasian
Other
If other race, please specify
Email / Correo Electrónico
*
Mobile Phone / Número de Teléfono
*
Zip Code / Código Postal
*
Preferred language for call back
English / Inglés
Spanish / Español
Is discretion needed for communications?
Discrete Phone Calls / Llamadas telefónicas discretas
Discrete Emails / Correos electrónicos discretos
Discrete Mailings / Envíos discretos
SMS
Fax
I agree to the Photo Permission / Autorizo el uso de mi imagen
*
Yes
No
I hereby agree that I have read and understand the following: Center South Behavioral Agreements; Sexual Harassment Policy; and the Release and Waiver Liability.
Center South Behavioral Agreement
*
Yes, I agree.
Click Here to Review LA LGBT Center's Terms of Service
LA LGBT Center's Terms of Service
*
I have reviewed and agree accept the LA LGBT Center's Terms of Service (Link Above)
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