Report Anti-LGBTQ+ Discrimination

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First Name *

Last Name

Email *

Address

City *

Zip Code

Phone Number *

What is the better way for us to reach you? *

Phone/Voicemail (It is safe for you to receive a phone call from GSE)

Are you contacting us for a matter related to school or being a student? *

Yes

If yes, what is the name of the school?

Are you contacting us for a matter related to health care discrimination? *

Yes

If the matter is health care related, was it:

Health Care Insurance Denial

Discriminatory Treatment in a Health Care Setting

Clear selection

In what county did the incident occur? *

Discrimination category (check all that apply)

HIV/AIDS Discrimination

Actual or Perceived Sexual Orientation Discrimination

Actual or perceived Gender Identity and Gender Expression Discrimination

Please provide a brief description of the incident for us to review. *

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