SisTers PGH Service Request Form
Please be advised these services are for the Transgender community of Pittsburgh & Allegheny County - All service request for our Trans and Nonbinary community members will be answered within 48 hours. Please check your emails to be sure you see any updates. All Fields With the '*' symbol next to them are required to submit this form. Your request will not be considered if these fields are not appropriately filled out. (WE ARE CURRENTLY OUT OF LYFT CODES) If you are a Trans Woman or Nonbinary BIPOC (BLACK, INDIGENOUS, PERSON OF COLOR experiencing homelessness or housing insecurities you can also apply to our Project T program through the website. Each individual must apply, thank you.
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Email (We will initially contact you through email, and request any documentation pertaining to a financial need if there is one, e.g eviction, shut-off notice, late bills, medical invoices etc, etc..)
*
1. Client Demographics
What is your full preferred name
*
What are your pronouns
(Short answer: e.g., she/her, they/them)
How do you identify in terms of gender? (Select all that apply)
*
Trans Woman
Trans Man
Non-Binary
Two-Spirit
Gender non conforming
Prefer not to say
Other (please specify)
What is your racial/ethnic identity? (Select all that apply)
*
Black or African American
Latine/Latinx
Indigenous (Native American or First Nations)
Asian American and Pacific Islander (AAPI)
Southwest Asian and North African (SWANA)
White
Multiracial
Prefer not to say
Other
What is your age?
What is your contact Information?
Phone Number and Email Address Please
City of Origin (if it's somewhere other then Pittsburgh)
What is your current living situation?
Unhoused (shelter, street, car)
Staying with friends/family (couch surfing)
Transitional housing
Renting or owning stable housing
Other (please explain)
Do you have dependents living with you?
Yes
No
How did you hear about SisTers PGH?
*
From one of SisTers PGH social media pages (Sisterspgh on Instagram, facebook, or TikTok)
Word of Mouth from a Friend, Relative, or Neighbor
United Way 2-1-1
UMPC Medical Center or Hosptial
Allies for Health and Wellbeing
Allegheny Link
Through an information Table at Peoples Pride or another event
Other
Phone Number
City
*
Zip Code
Address (If Applicable)
HIV Status
Positive
Negative
Narrative (What brought you here today, please explain in full detail)
*
Are currently Employed?
*
Yes
No
If yes, were do work?
Hourly Wage/Salary/Sex Work Income Per week?
*
How many hours are you eligible to work during each pay period?
*
If unemployed, are you looking for employment?
*
Yes
No
Are You Eligible/Receiving Governmental Assistance? If so please check all that apply. (If you need help getting registered for any government assistance programs please let your intake coordinator know during your first call)
Food Stamps/Cash Assistance
SSI/SSDI
Wic
CAP/LIHEAP
Medicaid
How much Governmental/Financial Assistance do you receive in total per month?
*
2. Service Request Type
What resources and/or recreational activities are you looking for at SisTers PGH? Select all that apply!
*
Clothing
Groceries
GED/Tutoring Support
Employment Navigation
Toiletries (Toothpaste, Toilet Paper, Soap etc)
Emergency Shelter
Mental Health Service Referrals
Dropping in at Sisters PGH (Sylvia’s Library, peer navigation, computer lab, or safe hang-out space)
Transportation Support (Bus pass / Lyft)
Rent/Utility Support (Please note: limited funding is available)
Other (Please explain)
Covid-19 Rapid Tests
N95 Masks
3. Follow-Up Questions Based on Selected Services
Clothing and Toiletries
What specific items do you need?
Groceries
• Do you have any dietary restrictions or preferences?
Name Change Project • Are you requesting assistance with:
Name change paperwork
Court fees
Document updates (e.g., State ID, Social Security Card)
Employment Navigation
1. What kind of employment are you looking for?
2. Do you need help with resume preparation, interview skills, or job search?
Yes
No
Emergency Shelter * Support Where are you currently staying?
Shelter
Couch surfing
Outside
Other (please specify)
Medical/Mental Health Referrals
What type of support are you looking for? (Select all that apply)
Mental health therapy (telehealth or in-person)
Primary care services
Hormone Replacement Therapy (HRT)
Referrals to specialized providers
GED/Tutoring Support
• What areas do you need help with?
Lyft Request - Please provide starting Address and Ending Address including date and time of request. (WE CURRENTLY DO NOT HAVE ANY LYFT CODES - WE WILL UPDATE WHEN WE HAVE MORE VIA OUR SOCIAL MEDIA)
Please add all additional context explaining these needs. (If requesting financial support please add amount along with additional context)
Confidentiality Agreement
Please read and sign below
All information shared in this application shall remain confidential and only shared with SisTers PGH leadership and caseworkers to better service you. If you wish to be referred to service providers outside of SisTers PGH you will be ask to complete an authorization form authorizing SisTers PGH to share your information with a 3rd party service provider. SisTers PGH will respond as soon as able to each request.
Print Name Here
Signature
Drop-In Services
Please note that our new drop-in space, the Stonewall Inn in Downtown Pittsburgh, is still under construction at this time. Please follow our social media for any updates and we apologize for any inconvenience in the meantime.
What drop-in services would you like to access? (Select all that apply)
Sylvia’s Library (quiet space for reading and learning)
Computer lab (for job and housing searches)
1-on-1 peer support with the Trans Resource Center Administrator
Hanging out and socializing in a safe space
How often do you plan to use drop-in services?
Daily
Weekly
Monthly
Transportation Support
What type of transportation support do you need?
Type a question
Bus Pass
Lyft Ride
What is the reason for your transportation need?
How much assistance are you requesting?
Please note that available funds may be limited.
Do you have documentation to verify your request? (e.g., lease agreement, utility bill)
*
Yes
no
Other
Have you received rent or utility support from Sisters PGH before?
No
Yes(when?)
What are your long-term goals in seeking support from Sisters PGH?
Is there anything else we should know about your situation to better assist you?
How did you hear about Sisters PGH?
Social media
Word of mouth
Referral from another organization
Website
Other (Please specify)
May we contact you for follow-up on your request?
No
Yes (Preferred method: Phone/Email)
Do you consent to your data being used anonymously for reporting and improving services?
Yes
No
Continue
Continue
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