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Denise O’Doherty

Denise O’Doherty

Licensed Professional Counselor, Licensed Marriage and Family Therapist, Drug and Alcohol Counselor, Registered Nurse

  • Relationship Counseling
    • Couples Therapy
    • Marriage Counseling & Family Therapy
    • Premarital Counseling
    • Domestic Abuse Counseling
    • IMAGO Relationship Therapy
  • Substance Abuse
    • Alcohol & Drug Addiction
    • SALCE Evaluations
  • LGBTQ+
    • Lesbian Therapy
    • LGBTQ+ Couples Therapy
  • Other Areas of Practice
    • Anxiety/Depression
    • BiPolar Disorder
    • Codependency/Personal Boundaries
    • Grief Counseling / Grief Therapy
    • Love Addiction/Love Avoidance
    • Overcoming Shame /Increasing Self-Esteem
    • Post Traumatic Stress Disorder
    • Dissociative Disorders
  • Gender Identity
    • Parents of Transgender Children
    • Gender Dysphoria
    • Cross-Dressing
    • Adult Children of Transgender Parents
  • Articles

Letter for Gender Affirming Surgery and Consent

"*" indicates required fields

Legal Name:
Birth Name:*
Address*
MM slash DD slash YYYY
Have you had previous Psychotherapy?*
Have you had laser hair removal or electrolysis?*
Have you changed your name or gender?*
Do you take hormones?*
Endocrinologist, general practitioner, internal medicine physician, Gynecologist or other?
Have you had facial feminization?*
Include procedures and Surgeon’s name and contact info.
Have you had voice coaching?*
Will you be maintaining your present job after you transition? (Initials)*
After surgery, I will be working*
After surgery, I will be a student:*
I can financially support myself:*
MM slash DD slash YYYY
Are your children aware of your plan to have surgery?*
Is sperm banking something that you would like to do prior to surgery as a reproductive option?*
I have a good network of friends who give me emotional support, accept me and support my transition.*
I am active in the transgender community.*
By signing this document below, I feel that I am psychologically and practically prepared to have Gender Affirmation Surgery, and, in addition, I am requesting a letter by Denise O’Doherty LPC MSN to be sent to my surgeon, confirming my informed consent. (Initials)
Clear Signature
This field is for validation purposes and should be left unchanged.
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