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  • Please include your legal first name.
  • Please include your legal middle initial.
  • Please include your legal last name.
  • Please include your preferred full name, if applicable.
  • Please state your age at the time you attended conversion therapy.
  • Please identify when you first started attending conversion therapy.
  • Please identify how long you were in conversion therapy.
  • Please identify the location you attended conversion therapy.
    Please state whether your conversion therapy experience was voluntary or not.
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