Hudson Valley LGBTQ Center

Provider Directory Information Submission

The following information will allow us to contact providers in the Hudson Valley and invite them to be included in our directory of LGBTQ affirming health care providers. Although we are asking you to provide some information about yourself, it is only so we can provide some demographics about the person who referred each health care provider (for example, "Referred by 60+ year old lesbian.") We will not associate your name or other personally identifiable information with the data we receive. In fact, you do not need to provide your name to make a referral.

Your email address (in case we have any questions):

Name of health care provider:

Location (town) of practice or full address and phone number (if known):

Type of provider, i.e. primary care physician, specialist, dentist, etc.:

Are you comfortable with being open or "out" with this provider?

Do you have any other comments about this provider?

Please answer the following questions about yourself.

I identify as:

My gender is:

My age group is:

Clicking submit will send this information to the coordinator of our health care providers directory. The information you share on this form will be used by us to make a contact with this provider to determine if they wish to be included in our provider directory. We will use the demographic information to give a general description of the person who made the referral.