PLS Trans & Queer Health Insurance Interest Form

This is not a form to request legal services. If you are looking for legal services, call our front desk at 828-253-0406.

Our services are free of charge to you. We may help you use your personal information to apply for health insurance but we will never ask for any type of credit card information. Any information you share with us is protected and will not be shared without your consent. If you are concerned about scams or fraud, call us directly at 828-210-3404 so you know who you are talking to. Your privacy and protection is important to us. You can read our Privacy Notice on-line here.

Are you a member of a community organization referring someone to this project? If yes, "you" refers to the person being referred.

YesNo

What is your full name? (Whatever you go by!)

What are your pronouns?

What is the best phone number for you?

What is your email address?

What's the best way and/or time to reach you? (such as emails, texts, phone calls before 12pm)

What health insurance situation are you looking for help with?
Do you have health insurance right now? Are you looking to access a specific type of care? Is there anything we can do to accommodate your needs?

Name of referring organization

As a referring community partner of Pisgah Legal Services, I certify that I have read the following consent aloud to the referred individual: “Do you give your consent for Pisgah Legal Services to contact you via telephone (including text messages) and/or email for the purpose of discussing your request for assistance and assessing eligibility for services from Pisgah Legal Services?”

Yes

The individual I am referring through this form has given their permission for me to share their contact information, as filled out above, with Pisgah Legal Services. Additionally, the individual being referred has given their express consent (in compliance with the privacy/confidentiality rules of my organization) for Pisgah Legal Services to contact them via telephone (including text messages) and email for the purpose of discussing their request for assistance and assessing eligibility for services from Pisgah Legal Services.

Yes

I consent for Pisgah Legal Services to contact me via telephone (including text message) and email, if provided, for the purpose of discussing my request for assistance and assessing eligibility for services from Pisgah Legal Services.

Yes

Contact Information