Section 1 - Referrer Information
This section is for information about you, the person making the referral. Although it is primarily designed for doctors, counselors, and other professionals, it is important for us to receive contact information for all of our referrers. We may need to contact you for more information. If you are referring yourself or a child for whom you are the primary caregiver, you may skip this section and proceed directly to Section 2.
Section 2 - Primary Patient/Client Contact Information
This section is for information about the primary contact for the patient/client. If the individual is an independent adult or an emancipated minor, they are their own primary contact. However, if the individual is a child or a dependent adult, their primary contact is their primary parent or legal guardian. If the individual has more than one primary parent or legal guardian, please enter the information of the one most readily contacted.
Section 3 - Checklist of Service Offerings
Please check any and all services the client is interested in receiving:
- Counseling - In-house low-cost scale counseling for children, youth, and families.
- Family Support Group - Adult-only group for parents, family members, and caregivers of trans and gender non-conforming children and youth.
- Trans Youth Group - Social and support group for trans and gender non-conforming youth ages 12-21.
- FreeZone - Monthly social event for the entire family. Past activities have included a trip to the pumpkin patch, a talent show, various craft projects, and a picnic in the park.
- Client Advocacy - Advocacy in schools, social service agencies, and other organizations and groups to respond to client's specific needs.
- Referrals - TransActive maintains a database of trans-savvy professionals to respond to a wide variety of legal and medical needs.
Enter any additional needs or interests in the textbox.
Section 4 - Children
If the primary contact (from Section 2) is a parent or caregiver, list their children here. Begin with gender non-conforming child(ren) first, then list others in chronological order. If the client is a child, they should be listed as Child #1.
Section 5 - Additional Information
Enter any additional information not already covered here.
Enter the two words in the red reCaptcha box to prove that you are human, then click the red "Submit Referral" button. If you would like to clear the form at any point, click the blue "Reset Form" button.
