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Youth Healthcare Navigation Intake
This form is for trans youth and their families to request assistance navigating gender-affirming medical care.
For additional SB150 resources:
https://southernequality.org/KYResources
For additional KY trans health resources visit:
kentuckyhealthjusticenetwork.org/trans-health-resources
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Name
*
Your answer
Pronouns
*
Your answer
Zip Code
*
Your answer
Email
*
Your answer
Phone
Your answer
Preferred Contact Method
*
Email
Phone
Text
Other:
Required
If Phone, Is It Okay To Leave a Message?
Yes
No
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Which of these apply to you?
*
I'm a trans person under the age of 18
I'm the parent, caregiver, or family member of a trans person under the age of 18
Other:
Required
Please briefly describe your situation
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Your answer
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