Safe Space Provider Nomination Form

Thank you for helping us create a directory of trusted, inclusive providers! Please fill out the form below to nominate a provider for consideration on our site.

YOUR DETAILS

First name

Last name

(If you would like to be contact in the event that further information is required on this nomination)

Post my display name with this review (optional)

Display Name (optional):

NOMINATED PROVIDER DETAILS

Are You Nominating Yourself?*

Yes, this is a self-nomination.

No, I am nominating another provider.

Providers Name*

Type of Service/Support Offered:*

Primary Location*

Servicing Locations

website / Socials

Does this provider identify as any of the following? (Self diagnosis valid)

Neurodivergent

Disabled

LGBTQIA+

No/Unsure

Chronically ill

Other

This information will not be posted publicly or with the review.

It will be only stored securely (with additional PII layers of encryption protection) for the purposes of nomination assessment & priority processing. For more details, please review our Privacy Policy.

YOUR REVIEW

Public review:

Please include specific experiences that made you feel comfortable or supported, any relevant accessibility features, approach or style, unique aspects of their service, or anything else you think others should know about this provider

Star Rating*

Confirmation & Terms

I confirm that the information provided here is accurate and true to the best of my knowledge, and is not false or misleading.

By submitting this form, you agree to our Terms & Conditions and understand that providing false or misleading information may result in the review being rejected or removed.

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