Patient Forms → Binder Request Lifting up the voices in the LGBTQ+ community, near and far.

Binder Request Form

Over the last several years, HCAI has provided free chest binders to hundreds of LGBTQ+ youth – and we're here to help you, too. Request yours today by filling out the form below.

Please note, HCAI binder program ships chest binder ONLY throughout the US and Puerto Rico. If you live outside of the US, to request a free chest binder please visit Point of Pride website

Learn more about Binder Do's and Don'ts

* Required field

Please note: Binders are only shipped to people over the age of 18.: *

Check here if you are over the age of 18.

Email Address: *

Your Information

First Name (as you wish it to appear on the mailed package): *

Last Name: *

Your Size: *For more information and direction on sizing see the sizing chart.

Your Address

Please double check that you include your complete mailing address. For example:

123 East Main Street

Apartment 456

New York, NY 100001

United States

Street Address: *Please check your address above and make sure it is complete, i.e.: apartment or unit number, binder will not be shipping if the address is incomplete.

Address Line 2:

Address Line 3:

State/Province: *

City: *

Zip/Postal Code: *

Country: *

Phone Number: *

Do's & Don'ts: *

I acknowledge that I have read and understand the do's and dont's of binding.

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.