The Center - Provider Application

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If you are a registered provider, you can login here and access your account.

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Patient Forms

Ideas about intake and health-history form questions

Screening Questions

Coming out to your health care providers.

Become a Provider

Add your practice to the Link online database.

Specialty^*:	Hold down the CTRL key to make multiple selections
Sub-specialty/ Area(s) of expertise:	please list
Languages spoken by yourself or staff:	please list
Are you Licensed^*:
License Number:
License Issuer:
License Expiration:
Are you Board Certified^*:
Certificate Issuer:
What health insurance carriers do you accept:	please list
Hospitals/Institutions you are associated with:	please list

Do you offer a flexible payment system for patients with no insurance?			Yes No
What or you patients/clients would you say identify as:
	% Gay	% Lesbian		% Bisexual
	% Heterosexual	% Transgender		% Intersex
What or you patients/clients are:
	% Caucasian/European	% African American		% Hispanic/Latino
	% Asian Pacific Islander	% Native American/Alaska Native		% Multiracial
Is your practice Transgender knowledgable?			Yes No
Is your practice Intersex knowledgeable?			Yes No
Does your agency or practice's intake forms and sexual/social history forms use inclusive language?			Yes No
Does your agency or private practice policies include GLBT patients/clients in their non-discrimation clause			Yes No
Would you like to receive GLBT-positive patient materials for your office/agency			Yes No
Would you or your staff be interested in receiving GLBT-sensitivity training			Yes No

Additional Info (will display on your profile)

We ask that you satisfy two of the following seven criteria. If you do not, please contact us for examples of language or policies for your practice. Please select any of the following that apply:
	I have documented completion of GBTI cultural competency training cirriculum, such as The Mautner Project's "Removing the Barriers" program.
	I have conducted medical screenings in the GBTI community
	I have conducted documented GLBI related health research
	I have volunteered my professional services to a GBTI organization, such as The Center, Colorado AIDS Project, or Project Angelheart.
	Other:
	Finally, by checking this box, I attest and commit to providing non-judgemental care of gay, lesbian, bisexual, transgender, intersex, and questioning individuals.