Intake Application

Intake Application
Personal Information
Name*

First NameLast Name
Pronouns*

She/HerHe/HimThey/ThemOther
Sexuality
If Other,
Gender
If Other,
Email Address*

Confirmation Emailexample@example.com
Want to stay updated? Join our Mailing List! Click the box below.*

Yes, I want to join the mailing list!No thanks!
Phone Number
Please enter a valid phone number.
Contact Preference
Do you consent to be contacted by a Resource Coordinator?*
Are you comfortable with having a zoom meeting?*
Birth Date*

MonthDayYear
Date
If under 18, are your parent(s) supportive?

YesNoOther
Do your parents need support? If so, what support do they need?*
City, State Zip Code*

City

State

CityState

Zip Code

Safety Information
Do you have any safety concerns?

Domestic ViolenceFinancialHousingMental healthSubstance AbuseOther
Please describe your safety situation.*

If you are in immediate assistance for facing mental and/or substance abuse please call the number below.
SAMHSA’s National Helpline – 1-800-662-HELP (4357)

SAMHSA is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders.

If you are feeling suicidal please call 911 or the following Trans Inclusive Suicide Hotlines below.

Trans Lifeline: (877) 565-8860

Trevor Project: 1-866-488-7386

If you are in an immediate need of safety please contact the hotline below:

National Domestic Violence Hotline: 1-800-799-SAFE (7233)

Did you know that American Trans Resource Hub offers a transgender support group every other Sunday? If you are interested click the link here.

Applying for Government Services
What program do you need support in applying to?

DisabilityFood Stamps/Supplemental Nutrition Assistance Program (SNAP)Medicaid/MedicareSubsidized Housing, Housing Vouchers, and Public Housing ProgramsSupplementary Security Income (SSI)UnemploymentWelfare of Temporary Assistance for Needy Families (TANF)
If you are already participating in a government program, which one?
What is your household income?
How many members are in your household?
If you have four household members, type 4.

Gender Affirming Items
What type of Gender-Affirming items do you need?

Binders (Chest Compression)Breast Forms and BrasDilatorsGaffs (Compression Underwear)ProstheticsProsthetic UnderwearShapewearOther
What type of clothing?
Shirts, Skirts, Boxers, etc.
What size are you?
Can you accept clothing at your address?
If we do not have the current funding to purchase items, would you be interested in a list of affordable gender-affirming items from trans-owned businesses?

Insurance
Do you have insurance
Who is your provider?
Describe your situation and what you need support with.
Ex: Find insurance that covers top surgery

Consent
The American Trans Resource Hub is a trans-led organization. We are not lawyers or medical professionals. We do the best we can to ensure that the resources we refer are vetted as trans-friendly to the best of our knowledge. We are not liable if you have a bad experience but we will do the best we can to make sure that you get access to the resources that you deserve.
Click the box below if you understand and agree to the statement above.*

Yes

Personal Information