Provider Recommendation Survey
We thank you for taking the time to tell us about the provider who values and understands your LGBT+ identity and the health needs that come with it. By anonymously filling this survey out, the provider will receive a survey that asks about their training, attitudes, and knowledge about LGBT+ patients' health. If their results support your recommendation, they will be entered into the Directory, and other LGBT+ community members can use this information to see that provider (and give feedback).
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Tell us about yourself (will remain anonymous)
Do you identify as LGBT+?
Clear selection
What is your age?
Clear selection
What is your race?
Are you Hispanic, Latino/a, or of Spanish origin?
What is your sex?
Clear selection
What is your gender?
How important is it to you that your provider incorporates LGBT+ care into their practice?
Not important at all
Very important
Clear selection
How likely are you to utilize a directory that promotes LGBT+-affirming providers?
Not likely at all
Very likely
Clear selection
Tell us about your provider
Name of specific provider required. Unable to accept recommendations of offices or organizations.
First Name of Provider *
Last Name of Provider *
Associated office or group of provider (if applicable)
Provider Specialty
Clear selection
Why this provider benefits the Peoria-area LGBT+ community
Additional Comments
Other things you feel we should know about this provider (can include languages they speak, insurances or payment methods they accept, their own gender identity, etc.)
Submit
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