form test Provider Form v2 Name(Required) First Last Pronouns Professional DesignationAdministrative email address(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneDo you identify as 2SLGBTQ+ (Two-Spirit, lesbian, gay, bisexual, transgender, queer, or other non-cisgender or non-straight identity)? Yes No Do you identify as Black, Indigenous, or as a Person of Colour? Yes No Directory listing informationDisplay listing publicly(Required) Yes No Organization nameWebsite Public email Please briefly describe your practiceHours of operationProfile image or logoAccepted file types: jpg, jpeg, png, gif.Are you accepting new clients? Yes No Can new clients self-refer to your practice? Yes No Do you offer services through Telehealth/Telemedicine? Yes No Which languages do you use in your practice?Type of services provided Aesthetics Childcare Community Organization or Social Services Conventional Health Care Fitness or Recreation Legal Other Religious or Spiritual Traditional or Alternative Health Care Other type of serviceWhat type of conventional health care services do you provide? Acupuncture Counselling or Therapy Dental Care Disability Services Endocrinology Home Care Manual Osteopathy Massage Therapy Midwifery Other Pharmacy Primary Care Psychiatry Psychological Assessments Psychology Reflexology Reiki Sexual and Reproductive Health Social Work Speech Language Pathology Surgery Traditional Chinese Medicine & Herbal Medicine Other type of conventional health serviceTrans wellness in your practiceDo you prescribe or maintain hormone replacement therapy (HRT) for gender affirmation? Yes No If you currently initiate HRT, which care model do you follow? Gender dysphoria diagnosis model according to the DSM-5 criteria Informed consent model Other Not applicable Do you have experience with initiating or maintaining gonadotropin-releasing hormone analogues (puberty blockers)? Yes No Please indicate which topics you are comfortable addressing with trans or non-binary patients: Social and legal transition goals including coming out, ID changes, gender affirming gear (e.g. binding, tucking, packing) etc. Physical transition goals including hormone replacement therapy, puberty blockers, gender affirming surgery etc. Sexual health including pleasure, sex work, relationships, STI testing etc. Reproductive health including fertility, pregnancy, and contraception etc. Screening for breast, cervical, prostate, testicular, and ovarian cancers as appropriate Intersex traits Mental health including trauma, addiction and drug use, anxiety and depression, gender dysphoria etc. Housing and food security Disability Neurodiversity Racism Are you on the HIV pre-exposure prophylaxis (PrEP) provider list? Yes No Please indicate the steps you have taken to provide inclusive and competent care for trans and non-binary clients: Member of a transgender health organization, such as the Canadian Professional Association for Transgender Health Attended courses or workshops in general LGBTQ+ inclusivity and health Attended courses or workshops in trans and non-binary inclusivity and health Received mentorship from health professionals experienced in trans and nonbinary health Administrative processes and records are inclusive of gender diversity and allow self-identification of gender, name, and pronouns Posters, pamphlets, and other materials are representative of gender diversity Privacy and confidentiality regarding gender identity is ensured, so that clients are not “outed” Assumptions are not made regarding clients’ genders, bodies, and relationships. An accessible single-user all-gender washroom is available Clinical staff have received training on gender inclusivity Administrative staff have received training on gender inclusivity AffirmationsPlease mark the checkboxes of the statements you agree with:(Required) I affirm that there is nothing wrong with being trans or non-binary and adopt a non-medicalizing approach to gender. I recognize that trans and non-binary people are who they say they are and am committed to making my practice inclusive and respectful of these identities. I acknowledge that trans and non-binary individuals have unique and individual needs. While I provide professional guidance on medical safety, I do not make assumptions or decisions about the right gender expression options for any patient. I believe in the rights of trans and non-binary people to bodily autonomy and access to life-affirming gender care. I am committed to ongoing learning about the specific health and wellness concerns of trans and non-binary individuals to ensure that I provide high-quality care. Select AllCAPTCHA
