LGBTQ+ Friendly Provider Interest Form

Thanks so much for saying hello! We'd love to add you to our directory, but first we need your information so we can follow up. WE's LGBTQ+ friendly provider directory is private, with names/practice information given based on specific patient requests. If you have any questions, reach out to Kota@WyomingEquality.org

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Contact Information

First Name Last Name

Pronouns (Optional)

Street Address (Optional)

Postal Code City State

Email What phone number can we reach you from during the work day? (Optional)

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(Optional)

Employer Information

Occupation Employer

I am retired

Background

What type of provider are you? (Optional)
What type of provider are you? is required.

Physician's Assistant

Nurse Practitioner

Social Worker

Mental Health Counselor

Medical Doctor

Other Other

If you have any specialities, please list them (Optional)

What county/counties do you work in? (Optional)

Do you have experience offering gender affirming care (hormone treatment, gender-focused talk therapy, etc)? (Optional)
Do you have experience offering gender affirming care (hormone treatment, gender-focused talk therapy, etc)? is required.

Yes

No

No, but I would like to learn

Are you interested in joining a gender affirming educational group that meets monthly for one hour? (Optional)
Are you interested in joining a gender affirming educational group that meets monthly for one hour? is required.

Yes

No

What LGBTQ+ supportive policies do you have in place? (Optional)

Do you know of any other providers that should be included in our LGBTQ+ Friendly directory? Add their name and email address below. (Optional)

Is there anything you would like Wyoming Equality to know about you or your practice? (Optional)

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