We're happy you're here!

This questionnaire is designed to filter out unwanted use of our resources. It helps to keep our platform secure and resources available to those in need. Once approved, you will receive an email granting you a Private Side Account.

START
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By clicking accept, you agree to Publicly Private's Terms of Service and Privacy Policy.

A
I accept
B
I don't accept
Please agree to the terms and conditions.
OK
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2
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Now, what should we call you?
Enter your name. You may remain anonymous by skipping the question.

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
3
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Nice to meet you, ________, how is your day going?

A
Great!
B
Could be better...
OK
4
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Awesome, ________! Mind telling us how you identify?
Select all that apply.
A
Straight
B
Lesbian
c
Gay
d
Bisexual
e
Transgender
f
Queer
g
Questioning
h
Intersex
i
Asexual
j
+
k
Prefer Not to Say
Submit
4
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Sorry to hear that, ________! Mind telling us how you identify?
Select all that apply.
A
Straight
B
Lesbian
c
Gay
d
Bisexual
e
Transgender
f
Queer
g
Questioning
h
Intersex
i
Asexual
j
+
k
Prefer Not to Say
Submit
5
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Was your identification not listed? If so, please tell us how you identify.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
6
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May we have your pronouns?                              
Select all that apply.
A
He/Him/His
B
She/Her/Hers
c
They/Them
d
Prefer Not to Say
OK
7
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Age is just a number but we kinda need to know... What is your age range?
OK
8
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On a scale from 1-10, how much of an LGBTQIA+ ally do you consider yourself?
Not at All
Best Ally
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
9
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Only a few more steps, ________! What are your current stress levels related to being LGBTQIA+?
Not at All
Extreme Stress
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
11
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We are sorry you are stressed. Which of the below categories best fit(s) your situation?
Select all that apply.
A
Personal
B
Friend or Family Concerns
c
Religious Believes
OK
12
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Are you currently experiencing any stress related to the LGBTQIA+ community?
Not at All
Extreme Stress
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
13
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________ , we need a little more information before we can approve your account. How are you planning to use Publicly Private's resources?
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
14
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What email should we use to contact you about your account?
If you haven't heard from a Publicly Private respresentative in 48 hours, please contact us on our Help Center.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
15
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With an account I am planning to..
Select all that apply.
A
Make a Donation
B
Help Advocate
c
Seek Informational & Awareness Resources
d
Use Sexual Health Resources
e
Join a Support Group
OK
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_______ , we are trying to get to know you a little more. Can you please tell us how you advocate for the LGBTQIA+ community currently or plan to in the future?
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
17
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What email should we use to contact you about your account?
If you haven't heard from a Publicly Private respresentative in 48 hours, please contact us on our Help Center.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
18
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What state do you live in?                                           
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
19
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What's your zip code?                       
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
20
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We currently are focused on sexual health resources for the LGBTQIA+ community of Tennessee. We can approve your account to use our other options. Would you like to proceed?
A
Yes
B
No
OK
19
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You're approved! What email would you like to use for your account?
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OK
We need a little more information from you. One of our representative will email you at ________ .
Congratulations, ________! You are now approved for Private Side.
Click here to finish signing up.
SET PASSWORD
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We're sorry to see you go. We'll be here if you change your mind.
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Could you please tell us which race or ethnicity best describes you?
Select all that apply.
A
Asian/Asian American
B
Black/African American
c
Hispanic/Latino
/Latina/Latinx
d
Middle Eastern/
North African
e
Native American/
American Indian/
Alaska Native/Indigenous
F
Native Hawaiian/Pacific Islander
G
White/Caucasian/
European
H
Multi-Racial/Multi-Ethnic (2+ races/ethnicities)
I
Prefer Not To Say
OK
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We are sorry you are stressed. Which of the below categories best fit(s) your situation?
Select all that apply.
A
Family (Including Chosen)
B
Harassment or Discrimination
c
Living Situation
d
Relationship(s)
e
Religious Believes
F
Self Expression
G
Sexual Health
OK