Service Provider Inventory Form

If you would like to be listed in a registry of service providers who provide wellness services to people who are GLBT, fill out this form and submit it to us by clicking on the Submit button at the end of this form.

Your Name:

The Name of your Organization (if applicable)

Mailing address:

Street
City
Province
Postal Code

Business Telephone:
Business Fax:           

Business Email:         
Web Site Address:   

1. I would summarize the services I provide as follows:

2. I provide services in the following language(s) (please check all that apply)

English
French
Other (please specify)

3. Which title best describes you? (please check all that apply)

Acupuncturist
Alternative health practitioner
Chiropractor
Counsellor (please specify )
Community worker (please specify )
Cultural interpreter
Dentist
Early childhood educator or parenting specialist
Educator
     Adults
     Children
     Youth
Financial advisor
Fitness/recreation professional
Funeral Service Provider
Holistic practitioner (please specify )
Home helper or homemaker, personal care assistant
Homeopath
Housing counsellor
Insurance specialist
Lawyer
Massage Therapist
Mediator
Naturopath
Nutritionist or Dietitian
Nurse
Physician
     General or Family Practitioner
     Other (please specify specialty )
Physiotherapist
Psychiatrist
Psychologist
Social worker
Other (please specify )

4. How would you categorize the services you provide? (check all that apply)

Medical and Related

Family Practice
Medical clinic
     Walk-in
     Youth
     Gender identity
     Other (please specify)
Medical specialty consultation and treatment
     Fertility and reproductive technology
     Endocrinology
     Reassignment surgery
     HIV/AIDS treatment
     Other (please specify)
Hospital Emergency services
Hospital Outpatient Clinic (please specify)
Hospital Day Surgery
Hospital Inpatient services
Mental health individual services (psychologist, social worker)
Mental health group
Psychiatric emergency
Psychiatric individual services
Dental services
Eye clinic
Pharmacy
Chiropractic Services
Other medical-related (please specify)

Prevention and Promotion

Fitness Training/Recreation
Health promotion and illness prevention
Nutrition services
Stress Management, Relaxation
Holistic wellness

Advice and Info

Information and referral
Phone
Internet
Published
Other

Counselling

Addictions/substance use
Spiritual
Phone
Peer support
Victim assistance
Abuse
Individual
Couple
Family
Advocacy

Support and Care

Home help
Personal care services
Nursing Services (at home)
Respite Care
Foster Care

Retirement and Nursing Home

Retirement Home Services
Nursing Home Services

Support for Daily Living

Financial Services
Legal Services
Training and Education
Life and health insurance
Literacy Training
Cross-cultural interpretation
Housing and shelter-related services
Parenting and child-related services (e.g. child care)

Alternative Health

Massage
Acupuncture
Naturopath
Homeopath
Other Alternative Health (please specify)

5. What qualifies you to provide the services you provide? (Please list experience, qualifications, credentials, and/or qualities.)

6. Are there specific sub-groups of the GLBT population that you specialize in working with?(please check all that apply)

Gay men
Lesbians
Two-spirited
Bisexual Men
Bisexual Women
Transgendered
     Male to female
     Female to male
     Intersex
     Other:
Seniors
Youth
Couples/Partners
Those with mental illness
Children of parents who are GLBT
Other family members of people who are GLBT
Those with Chronic illnesses
     HIV/AIDS
     Other:
Those with disabilities
Women in general
Men in general
Aboriginal
People from specific ethno-cultural backgrounds (please specify)
Other:

How You Would Like this Information Used

7. Would you give your permission for your name to be listed in an unpublished registry of GLBT-positive service providers that would be made available to each practitioner listed in the registry?

Yes
No

8. Would you give your permission to be listed in a printed and/or an on-line publication for the general GLBT public which identifies resources are available to them in Ottawa?

Yes
No (if no, why not?)

Help us Find Other Service Providers

If you know of other Service Providers who might like to be included in our inventory, Please provide information about them below. An email address or telephone number would be most useful. THANK YOU!

Thank you for your participation!

We will let you know when the Service Provider Inventory is available.

Please click Submit below to submit the information above to us. Click Reset if you want to start over.

Updated: 25 Jan 01