First Contact Questionnaire

These questions are designed to help us pair you with a compatible Peer Contact. Please answer the questions that you are comfortable with and find relevant. All information will be kept private.

Safe Space Campaign

Louisiana State University

335 LSU Student Union Building

Baton Rouge, LA 70803

Telephone: (225) 578-4339

Fax: (225) 578-7135

E-mail: LGBTQProject@lsu.edu

Name:
*Email Address:

Please self-identify
Age:
Race:
Gender Identity:
Sexual Orientation:
Religious Affliliation:
Are you a practicing member of stated faith?	yes no

Background: Please briefly state your situation (Relationship with family, how many people you are out to, friendships, etc.)


Needs/Concerns: Please state any particular questions that you may have that you would like to ask your peer contact:


* Required