Submit a Provider, Maine Queer Health

Provider Photo	Please upload a photo of the provider to be added to the listing, if you are able
Name of Provider
Professional Credential (MD, DO, FNP, LCSW, etc.)
Website	Provider's website
City	City or cities where provider practices
County	County Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York County or counties where the provider practices
Region	Region Greater Portland Greater Bangor Mid Coast Northern Maine Greater Lewiston Central Maine Western Maine The County Southern Maine Downeast Telehealth
Phone	Provider's primary contact number
Practice Name
Field of Practice	Field of Practice Mental Health Primary Care Sexual and Reproductive Health Transgender Care Pediatric and Youth Care Holistic Care Dental Care Elder Care Legal Services Community Support and Advocacy Veteran's Services Substance Use Care Psychology Pharmacy Surgical other: What field of medicine (or other service) does the provider practice?
Services Offered
Does this provider offer a sliding fee scale?	Does this provider offer a sliding fee scale? Yes No unknown
Does this provider accept MaineCare?	Does this provider accept MaineCare? yes no unknown
Why do you believe this provider should be listed in this database?
What continuing education about treating LGBTQ+ patients does this provider participate in?
Your Name
Pronouns
Email Address	Your Email Address
Are you a community member or a provider?	Are you a community member or a provider? community member provider clinic representative
Identity	Identity Transgender Cisgender Other Prefer not to disclose other:
Orientation	Orientation Straight Gay Lesbian Bisexual Pansexual Queer Ace/Aro (asexual/aromantic) other:
Gender	Gender Male Female Non-binary Gender Fluid Genderqueer Prefer not to say other:
How would you describe your race?
Are you disabled?	Are you disabled? Yes No Prefer not to disclose
Disability Info
Age Range	Age Range 18-24 years old 25-30 years old 30-40 years old 40-65 years old 65+ years old
Do you have any other identities you consider relevant or qualifying to your evaluation of a provider? If so, we invite you to share here: