Typeforn

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.

Begin Analysis

press Enter

Takes X minutes

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

Description (optional)

A

I accept

B

I don't accept

Please agree to the terms and conditions.

OK

2

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

Nice to meet you, ________, how is your day going? *

A

Great!

B

Could be better...

OK

4

Awesome, ________! Mind telling us how you identify? *

Choose as many as you like

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

Sorry to hear that, ________! Mind telling us how you identify? *

Description (optional)

Choose as many as you like

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

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

May we have your pronouns? *

Choose as many as you like

A

He/Him/His

B

She/Her/Hers

c

They/Them

d

Prefer Not to Say

OK

7

Age is just a number but we kinda need to know... What is your age range? *

OK

11

We are sorry you are stressed. Which of the below categories best fit(s) your situation?

Description (optional)

Choose as many as you like

A

Personal

B

Family Concerns

c

Religious Believes

OK

13

________ , 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

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

With an account I am planning to..*

Description (optional)

Choose as many as you like

A

Make a Donation

B

Help Advocate

c

Seek Informational & Awareness Resources

d

Use Sexual Health Resources

e

Join a Support Group

OK

16

_______ , 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? *

Description (optional)

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

OK

17

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

What state do you live in? *

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

OK

19

What's your zip code? *

Description (optional)

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

OK

20

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? *

Description (optional)

Choose as many as you like

A

Yes

B

No

OK

19

You're approved! What email would you like to use for your account? *

Description (optional)

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. We will send you a verification email to confirm.

We're sorry to see you go. We'll be here if you change your mind.

6

Could you please tell us which race or ethnicity best describes you? Select all that apply. *

Description (optional)

Choose as many as you like

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