Intake Forms

Providers

When people seek services for any reason, it is important to build a rapport so that they feel comfortable discussing their concerns and questions.  This is especially true when people seek services for sensitive issues such as partner abuse.  Disparities in access to medical, social, and mental health services between LGBTQ people and their non-LGBTQ peers are documented.  Fear that a provider may not be culturally competent about LGBTQ issues or hostile is an additional barrier LGBTQ people face in accessing services.

Having intake forms that appropriately ask about gender identity, sexual orientation, and partnership status is one way that providers of medical, social, mental health, and partner abuse-related services can demonstrate cultural competence.  Intake forms are often the first documents that clients see and can help to create a good impression and foster trust between LGBTQ people and a provider.  A few simple steps can make intake forms more inclusive of gender identity and sexual orientation.  To be inclusive of people of all genders, consider using the language listed below on intake forms.

Sample Intake Form Fields

1.  Your preferred name:

 

________________________________________

 

2.  Gender:

 

________________________________________

 

 

3.  What is your relationship status?

 

________________________________________

 

OR

 

4.  What is your relationship status (circle one)?

 

Single     Widowed     Divorced     Married     Partnered    Dating

 

5.  Who do you live with?  Or, who is your emergency contact?

 

________________________________________

 

FOLLOWED BY

 

6.  What is your relationship to this person?

 

________________________________________

LGBT People

It is important for LGBTQ people to be able to discuss their health and well-being with service providers openly.  LGBTQ people take ownership of their own health and care by engaging in open discussion with providers.  LGBTQ people can also act as advocates for themselves and other people in the LGBTQ community by helping to educate providers.

Other Resources