Sample culturally competent intake form

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Seattle & King County
401 5th Ave., Suite 1300
Seattle, WA 98104

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	Home » GLBT Health » For healthcare providers » Sample intake form

Gay, Lesbian, Bisexual and Transgender Health
Sample culturally competent intake form

Note: This is not intended to be a complete patient intake instrument, but for incorporation into your existing form.

What is your gender?

	Male
	Female
	Transgendered (check one: MTF FTM)

What is your relationship status?

	Single
	Legally married
	Domestic partner relationship
	Divorced / separated
	Widowed
	Other (please specify):___________________________________

Gender of current sexual partner(s) (circle all that apply)

	Male
	Female
	Transgendered (please specify):________________________
	Not currently sexually active with others

Gender of past sexual partner(s) (circle all that apply)

	Male
	Female
	Transgendered (please specify):________________________
	Not currently sexually active with others

Are you in a relationship with another person right now?

	Yes
	No

If yes, is this relationship a good one for you?

	Yes
	No
	Not sure
	Not in a relationship right now

Do you need birth control?

	Yes
	No

If yes, are you currently using birth control?

	Yes (please specify type):________________________
	No

Do you have any questions about sex or sexuality?

	Yes (you may state your question here or we can talk in person) ___________________________________________________ ___________________________________________________ ___________________________________________________
	No

Do you or your partner(s) have any children?

	Yes
	No

Do any children live in your household?

	Yes
	No

Do you need to discuss any of the following with us? (check all that apply)

	Safety concerns now or a history of physical, sexual or emotional abuse
	Getting along with parents
	Getting along with friends
	Getting along with partner
	Privacy/confidentiality
	Loneliness, depression, anxiety or problems eating or sleeping
	Weight, bodybuilding or eating concerns
	Safer sex or sexually transmitted diseases
	Pregnancy test or options for starting, ending or continuing a pregnancy
	Other (please specify):________________________

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Racial and Ethnic Discrimination in Health Care Settings (PDF)

1 in 10 of King County adult residents believe they have experienced discrimination in health care settings in the past year. For persons of color living in King County these occurrences are reported much more frequently.

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Updated: Monday, November 26, 2007 at 11:46 AM

All information is general in nature and is not intended to be used as a substitute for appropriate professional advice. For more information please call 206-296-4600 (voice) or 206-296-4631 (TTY Relay service). Mailing address: ATTN: Communications Team, Public Health - Seattle & King County, 401 5th Ave., Suite 1300, Seattle, WA 98104 or click here to email us.

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