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Tell us about your practice. The Consortium will review your submission and reach out before listing you publicly. Some answers stay private, those are clearly marked.

Step 1 of 6

About you

Your name, pronouns, credentials, demographics, and how you'd like to be listed.

Chosen Name (first and last)*

Pronouns*

Check all that apply.

She/her/hers

He/him/his

They/them/theirs

Other:

Please list your credentials*

What is your race or ethnicity?

Please select all that apply or write in however you prefer to identify.

Display my race/ethnicity on my public listing

LGBTQIA+ identity

Are you a member of the LGBTQIA+ Community?*

Yes

Would you like your LGBTQIA+ member status listed on our website?*

Yes

Yes, but only as "a member of the community"

Please list that I am an ally

Grand Rapids LGBTQ+ Healthcare Consortium

About Contact

501C3 Status Since 2020

info.grlgbtqhcc@gmail.com Donate to the Stronger Together Campaign

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Maintained and Updated by Dr. Jay Knight

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