Your Information

First Name

Last Name

Pronouns

Title/Role at Agency

I would like to receive future email updates about GLAD’s work.If you are already on this list, you won't start receiving two emails. Unchecking this box will unsubscribe you from GLAD's email list.

Phone Number

Agency Information

Agency Name

Brief Description

Website

Agency Address

Agency Address 2

City

State

Zip Code

Service Region

Please specify

In which areas of practice do you have expertise and/or are willing to receive referrals? (Select all that apply)

Please specify

Accessibility

If your agency provides services in languages other than English, please specify below. (Select all that apply)

Please specify

Do you have communication services for the hearing impaired?

Is your agency wheelchair accessible?

Working with transgender and nonbinary clients (select all that apply)

My agency is committed to supporting and respecting trans and nonbinary peopleMy agency has experience supporting transgender peopleI would like resources about how my agency can better support trans and nonbinary people

Does your agency have an income threshold for services?

Please specify

Does your agency charge for services?

Please specify

Is there other information you would like to share?

Contact Information