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LGBTQIA+ Patient Navigator Form

We can help you find a primary care provider (PCP), specialty care or mental and behavioral health provider, or help you connect with a support group. In addition to in-person visits, our providers are available for virtual visits with patients that are physically located in Michigan to receive care.

1. First Name *This question is required.

2. Last Name *This question is required.

3. Preferred Pronouns

4. Email *This question is required. This question requires a valid email address.

5. Phone Number (optional)

6. Preferred Contact Method *This question is required.

7. What county are you in? *This question is required.

8. Are you seeking Adult or Pediatric services? *This question is required.

9. Services you are looking for *This question is required.

Primary Care Provider
Behavioral Health Provider
Specialty Care Provider
Connection with Community Resources/Support Groups
Other - Write In Please enter an 'other' value for this selection.

10. What kind of community resources or support groups are you looking for? *This question is required.

10. Do you have a preference for gender identity of your provider? *This question is required.

10. Do you want virtual care or in person care? *This question is required.

10. Are there specific treatments you are looking for in primary care? *This question is required.

10. Are there specific modalities that you wish for them to be trained in? *This question is required.

10. What type of specialist are you looking for? *This question is required.

10. Is there a specific service you would like from your specialist? *This question is required.

10. How did you hear about us?

11. Is there anything else you would like us to know?