Provider Self-Input Form

Thank you for your interest in being a part of RAD Australia and your commitment to providing safe and affirming care to the trans, gender diverse, intersex, queer, lesbian, gay, bisexual and asexual communities! While we are committed to including service providers from a wide range of professions, many of the questions are specifically aimed at health care providers. If any of the questions on this form are not applicable, please skip them We've designed this questionnaire to give us an in-depth understanding of your services, but the form should take no more than 20 minutes for you to complete. Many of the questions are designed to give us an understanding of your provider services or organization.

Although this website is for the LGBTIQ community as a whole, we're interested in hearing how your services or organisation can support the trans, gender diverse and intersex communities in particular. Your answers to these questions will make community members feel more comfortable seeking your care. We encourage you to be as in-depth as possible in your response to these questions. If very little information is included, we may not feel comfortable adding you to RAD Australia. If you need any help, clarity, or guidance, please contact support@radaustralia.org.au for assistance.

For detailed instructions on how service providers can submit a service listing check out our Service Provider User Guide.

Provider Information

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Formatting: First Name, Last Name, Titles (ex. Jane Smith, LCSW)**If you only have an organisation name, please put that in this box**

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Formatting: Organisation Name (ex. Sage Community Health Collective) **If you only have an organisation name, please put that name in the "Provider Name" box**

Please write a brief description of your organization and your theory of care in the text box. This could be a mission statement or similar.

Formatting: Street #, Street Suite # (ex. 5555 N. Main St, #2)

If it‘s a landline phone number, please include the state prefix eg, 08, 02

If it‘s a landline phone number, please include the state prefix eg, 08, 02

If you have multiple practice locations, please put in the other addresses and contact numbers below. **Multiple locations can be separated with a semi-colon (;)**

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If available.

Specific Formatting: Days: Mon, Tues, Wed, Thurs, Fri, Sat, Sun; Hours: 9 am – 4:30 pm; Extra Specifics: (Walk-ins, Appt Only, New Patients) ***(Long Formatting Example: Mon, Tues, Wed - 9 am – 4:30 pm (By Appointment Only); Thurs-Sat – 10:30 am – 7 pm (Appointments and Walk-ins); Sun – Closed)***

If this is applicable, please use the formatting above and preface the different hours with each new location.

Check or list (in the "Other" box) as many languages that are applicable. If listing multiple languages in the "Other" box, please separate them with a semi-colon (;)

Who do you serve, specifically? Are there any restrictions on who you serve, such as age or gender identity? We have given you some general headers that encompass several community-specific identities, but urge you to be specific in the "Other" box.

Do you provide any of the following services related to gender identity? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to addiction? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to medical services? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to gender identity? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to gender identity? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to gender identity? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to surgery? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to cosmetics? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to dental? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Do you provide any of the following services related to gender identity? (Select all that apply) **If one or more of the services that you provide does not appear in the list, please put it in the ‘Other’ box (you can include as many services as you would like separated with a semi-colon (;)**

Which of the following best describes where you practice? If you serve in multiple settings, please check all that apply. Even if you are not a medical provider, please let us know, to the best of your ability, how your practice is set-up.

The following are questions that community members have identified as being important to helping them feel safe making care decisions. Please answer truthfully, and in reasonable depth.

Please answer the following in the text box: In what capacity have you served LGBTIQ people? For how long have you been serving LGBTIQ people?

Please answer the following in the text box. Have you and your staff received any specialized education or training around providing services to LGBTIQ people? What types of education? How often?

Please answer the following in the text box. How do you approach providing care to LGBTIQ people? How do you define safe and affirming care for LGBTIQ peoples?

Please answer the following in the text box. What services do you provide to LGBTIQ youth? How do you protect their confidentiality? Do you require parental consent?

Please answer the following in the text box. How does your practice/organization accommodate persons with disabilities during their visit? Do you have specialized equipment (such as scales or transfers)? Do you have personal assistants available? Do you have braille forms available?

Please answer the following in the text box. How are trans, gender diverse, gender questioning and/or intersex individuals addressed during intake and processing? Are there options for preferred name and pronoun on your forms? How do you handle discrepancies between trans, gender diverse, gender questioning and/or intersex status affirming care, and limitations that may or may not be placed on you by a system (ex. Electronic Medical Records)?

Please answer the following in the text box. How is your intake / front office staff trained in providing affirming services to trans, gender diverse, gender questioning and/or intersex people?

Please answer the following in the text box. How does your organization create a welcoming physical space for LGBTIQ young people? To best answer this question, think about the information you provide, images you display, and the structure within your organization.

Please answer the following in the text box. How do you approach obstacles to providing safe and affirming care for trans, gender diverse, gender questioning and/or intersex people? For example, many providers have issues with intake forms, EMR records, or other staff members. If there is an issue, is there a clear process for an individual to inform you of issues? Are you in a larger setting where you, as a provider, may not have some control over staffing? What would happen if providers in your office refused care to trans, gender diverse, gender questioning and/or intersex people?

Please answer the following in the text box. Is there anything that you weren’t asked that you think is important for folks to know?






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