Stonewall Youth Online Intake
Hello! We’re happy that you’re thinking about coming to Stonewall Youth. We’d appreciate it if you’d fill out this short form and email it to us at When we receive your form, a staff person will call you to give you a bit more information about Stonewall and give you directions to our space. (We can also email you if you prefer.) If you don’t want to fill out this form, you could do an intake over the phone by calling (360)705-2738. Please give us a call or send us an email if you have any questions!
<3 Stonewall Youth staff
Date:
Name(you don’t have to give us your legal name-just the name you prefer):
Age:Date:
1. Do you speak of understand another language better than English? If so, what language?
2. How did you hear about Stonewall? (examples: Facebook, friends, went to an event…)
3. What brings you to Stonewall?
4.What is your preferred gender pronoun:(We ask this question because we don’t want to assume anyone’s gender identity and we want you to tell us how you want to be identified! Examples include using “she” or “they” or “he” pronouns, etc.) ______
Stonewall provides a number of free activities and programs for queer youth ages 21 and under. Once you come to Stonewall you’ll hear about all sorts of fun events. However, some of our most important weekly events include:
Drop in hours every week (Wednesday 3-5pm and Friday 4-8pm)
Support Group every week on Wednesday from 5-7pm
5. Do you have any questions about our weekly programming?
We have a few basic agreements that we like to share with people before coming to Stonewall, they include:
+ In Support Group you must maintain confidentiality- this means not sharing names of people who attended and the things people shared in Group.
+ Please try to have new people who are interested in Stonewall call or submit an online intake first before you bring them.
+Be mindful about going up to people who you know from Stonewall Youth at other events because it could potentially “out” them.
+ Stonewall is a sober space. Please don’t use drugs or alcohol before coming to Stonewall Youth or during Stonewall activities.
6. Do these agreements work for you? Yes ______No ______
7. Do you have any other questions or concerns before coming to Stonewall?
8. What’s the best phone number to reach you at?(If you are living with a disability that prevents you from talking on the phone, give us your email and we will contact you that way)
______
8. Is it okay to leave a message saying that we are calling from Stonewall Youth?
Yes _____ No______