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Wellness Services Interest Form
This form is to signify your interest in TransPonder's LGBTQIA2S wellness services.
After filling out this interest form, someone from our behavioral health team will get in touch with you.
Please email wellness@transponder.community with any questions, or call
541-321-0872.
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* Indicates required question
Email
*
Your email
What services are you interested in? Select all that apply.
*
Individual Therapy
Group Therapy
Peer Support Services
Substance Use Counseling
Social/Peer Group
Employment Assistance
Basic Needs Resources (EX: food, housing) Please indicate specific need at "Other".
Resource Navigation
Gender-affirming Services (EX: products, support letter) Please indicate specific need at "Other".
Legal Document Changes (EX: affidavit, driver's license, birth certificate, passport)
Other:
Required
What is your first name? (What would you like us to call you? It doesn't have to be your legal name.)
*
Your answer
What is your last name?
*
Your answer
What are your pronouns?
*
Your answer
What is your date of birth?
*
MM
/
DD
/
YYYY
What is your phone number?
*
Your answer
What method of communication do you prefer?
*
Email
Phone Call
Text
Other:
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