Survey to U.S Leads

1
Which U.S. state do you currently live in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
NewHampshire
NewJersey
NewMexico
NewYork
NorthCarolina
NorthDakota
Ohio
Oklahoma
Oregon.Pennsylvania
RhodeIsland
SouthCarolina
SouthDakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
WestVirginia
Wisconsin
Wyoming
Washington
D.C.
US Territories: American Samoa, Guam, Northern Mariana Islands, Puerto Rico, U.S. Virgin Islands
Other: I am not based in the U.S
2
What is your pathway?* This field is required.
Masculinising
Feminising
Non-Binary
3
Are you currently accessing gender-affirming medication (such as estrogen, testosterone, or puberty blockers)?* This field is required.
Yes
No
4
That’s great, now please tell us where are you currently getting your gender-affirming medication from?* This field is required.(select all that apply}
A personal doctor
Planned Parenthood
Telehealth service (like Plume, Queer Doc, or Folx)
An online pharmacy
From outside the U.S.
Other
5
On average how much do you spend per month on gender-affirming care?* This field is required.
$10-$50
$51-$100
$101-$150
$151-$200
$201-$250
$251+
6
How much of this is the cost of medication?* This field is required.
>25%
25%-50%
50%-75%
75% - 100%
7
Does your insurance provider cover or contribute to the cost of your gender affirming care?* This field is required.
Yes, fully covered
Partially covered
Not covered
I don’t have insurance
8
Who is your health insurance provider (if applicable)?* This field is required.
Blue Cross Blue Shield
Aetna
Cigna
UnitedHealthcare
Kaiser Permanente
Medicaid
Medicare
Tricare
I’m not sure
I don’t have insurance
Other
9
What would make you consider changing your gender-affirming care provider?* This field is required.
A purely online service
A cheaper monthly service but one that is fully automated (less people)
A service that lets me choose what medication I want so I can control my health.
A service that makes life easy by choosing my medication for me based on medical evidence for best results.
None of these
10
Email* This field is required.
example@example.com
11
Your Name* This field is required.
First Name
Last Name
Should be Empty: