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ACLP LGBTQIA2S+ caucus questionnaire
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* Indicates required question
Do you plan on joining the caucus?
*
Yes
No
Maybe
You identify as:
*
A member of the LGBTQIA2S+ community working with the community
A member of the LGBTQIA2S+ community not currently working with the community
An ally working with the LGBTQIA2S+ community
An ally not currently working with the LGBTQIA2S+ community
Other:
Do you identify as Two Spirit?
Yes
No
Clear selection
Do you identify as intersex?
Yes
No
Clear selection
Which of the following best describes your gender identity?
Cisgender
Transgender
Man
Woman
Non-binary
Agender
Genderfluid
Genderqueer
Transmasculine
Transfeminine
Demigender
Bigender/ trigender/ polygender
Not sure
Other:
Which of the following best describes your sexual orientation?
Asexual
Demisexual
Bisexual
Pansexual
Gay
Lesbian
Aromantic
Demiromantic
Biromantic
Panromantic
Monogamous
Ethically non-monogamous/ Polyamorous
Not sure
Other:
Are you a member of the BDSM/ kink community?
Yes (please select other and specify, if you are comfortable doing so)
No
Not sure
Other:
You are a:
*
Medical student
Psychiatry resident
Consultation-liaison psychiatry fellow
Other psychiatry fellow
Consultation-liaison psychiatrist
Adult psychiatrist
Child & adolescent psychiatrist
Other psychiatrist (please select other and specify - addictions, geriatric, forensic, etc.)
Early career psychiatrist
Mid career psychiatrist
Late career psychiatrist
Non-psychiatric medical trainee (please select other and specify which specialty/ subspecialty)
Non-psychiatric physician (please select other and specify which specialty/ subspecialty)
Nurse practitioner student
Nurse practitioner trainee (please select other and specify which specialty)
Nurse practitioner (please select other and specify which specialty)
Physician associate student
Physician associate trainee (please select other and specify which specialty)
Physician associate (please select other and specify which specialty)
Other health profession student (please select other and specify - psychology, social work, counseling, nursing, pharmacology, etc.)
Other health profession trainee (please select other and specify - psychology, social work, counseling, nursing, pharmacology, etc.)
Other health professional (please select other and specify - psychology, social work, counseling, nursing, pharmacology, etc.)
Other:
Required
Do you identify as a person of color?
Yes
No
Clear selection
Do you identify as Latine/ Latinx?
Yes
No
Clear selection
How often would you like to meet as a caucus?
*
Monthly
Every 2 months
Every 3 months
No preference
Other:
What sorts of activities are you interested in?
*
Educational events
Annual meeting social events
Peer supervision/ case discussion
Peer support
Nothing in particular
Other:
Required
You are interested in being a:
*
Mentor
Mentee
Neither
Required
You are looking for collaborators for:
*
Presentations at ACLP
Presentations at other conferences
Authorship/ writing
Advocacy efforts
Clinical efforts
Creative projects
None of the above
Other:
Required
What specific efforts and/or changes do you visualize our caucus being a part of within ACLP?
Your answer
Would you be interested in having a caucus-sponsored workshop at the annual meeting?
*
Yes
No
What are some of your recent accomplishments that we can celebrate as a caucus?
Your answer
Other comments/ ideas/ suggestions/ feedback:
Your answer
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