Business or Organization Name
*
Name of Contact
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
What primary category of services do you provide?
*
Which population(s) do you specialize or prioritize providing safe, affirming services for?
*
Select all that apply.
If you selected "Two or more" for the above question, which populations do you provide services for?
How do you ensure that you are providing an affirming and safe culture for all of your customers/clients?
*
If applicable, does your intake paperwork or telephone intake process offer inclusive identification options, including partner and gender/pronoun options?
*
If you answered "no" to the prior question, would you be willing to change your intake paperwork and processes to be more inclusive prior to approval as a Community Ally?
Please provide links for your company/organization's website and/or social media:
*
If a customer/client provided feedback that their experience of your services was NOT safe and affirming for any reason, what action would you take to address the issue?
*
Additional Notes
*
