Technical Assistance Request Form Are you a Federally Qualified Health Center? YesNo Contact Information Name: Email: Phone: Organization Name: Organization Location: Please briefly describe your organization. What prompted you to seek training/technical assistance on LGBTQIA+ health? Who is the intended audience? CliniciansFront-line staffSpecialty providersAll-staffPatients/FamiliesClientsLeadership/Executive staffOther What is the size of the audience? Is there a particular topic you would like the training/technical assistance to address? (Hold CTRL to select multiple topics) Sexual Orientation/Gender Identity (SOGI) Data CollectionHealth Equity 101 (terminology, disparities, basic affirming practices and care)HIV Prevention & TreatmentOther LGBTQIA+ Terms/DefinitionsCreating Inclusive and Affirming Environments for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsLGBTQIA+ (or specifically Transgender and Gender Diverse) Care: Stigma, Disparities and TerminologyImplicit Bias in Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsPrimary and Preventive Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsMental Health Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PeopleEffective and Affirming CommunicationSexual Orientation/Gender Identity (SOGI) Data CollectionLGBTQIA+ Older AdultsLGBTQIA+ YouthOther Do you have an existing educational program? YesNo What type of training/technical assistance are you looking for? Any specific goals or outcomes to achieve? Do you have proposed dates or a timeline for training/technical assistance? YesNo Is the date/time flexible? YesNo If yes, how so? Are you open to virtual training/technical assistance? YesNo If not, are you able to pay for travel costs? YesNo Do you have funding that you are able to put toward training/technical assistance? YesPotentiallyNo Please indicate budget Please explain Is there anything else we should know about your training request?
