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Denise O’Doherty

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

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Letter for Gender Affirming Surgery and Consent

Legal Name:

First Middle Last

Birth Name:

First Middle Last

Today's Date:

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Email:

Date of Birth:

MM slash DD slash YYYY

Current Age:

Information about Previous Psychotherapy

Have you had previous Psychotherapy?

Yes

No

Please Provide Information about Previous Psychotherapy - when, where, with whom?

Have you had laser hair removal or electrolysis?

Yes

No

Provide more information about your laser hair removal or electrolysis - when, where, with whom?

Have you changed your name or gender?

Yes

No

Date the change was granted:

State where change was granted:

County where change was granted:

Do you take hormones?

Yes

No

When did you begin hormones?

How long have you been on hormones?

What hormones are you presently taking?

M.D who presently prescribes for you:

What type of doctor prescribes your hormones?

Endocrinologist, general practitioner, internal medicine physician, Gynecologist or other?

Have you had facial feminization?

Yes

No

Please provide information about the facial feminization procedures you have had:

Include procedures and Surgeon's name and contact info.

Have you had voice coaching?

Yes

No

When did you have voice coaching and who was your coach?

Do you presently have any significant medical conditions?

Any known allergies?

Are you taking any medication on a regular basis? (Please list)

I have been living full-time since:

Where do you work presently?

How long have you been there?

What is your job title?

Will you be maintaining your present job after you transition? (Initials)

Yes

No

If not, where will you be working after your surgery?

Job title:

After surgery, I will be working

Full Time

Part Time

N/A

After surgery, I will be a student:

Full Time

Part Time

N/A

If retired, how long have you been retired:

I can financially support myself:

Yes

No

Present Marital Status:

Names and ages of children:

Date of any past divorces: (if applicable)

MM slash DD slash YYYY

Who in your immediate biological family is supportive of your surgery?

Who in your immediate biological family is not supportive of your surgery?

Are your children (if applicable) aware of your plan to have surgery? Please give names and ages in the yes or no category.

Yes

No

Is sperm banking something that you would like to do prior to surgery as a reproductive option?

Yes

No

If you have already done this, when?

I have a good network of friends who give me emotional support, accept me and support my transition. (Initials)

Yes

No

This network of friends consists of approximately people.

The following people / person will be accompanying me to surgery and will be included in my post surgery care:

Please list any Civic, Social, Professional Organizations where you are a member or attend regularly.

I am active in the transgender community.

Yes

No

If so, what do you do in the transgender community?

Who will be writing the second letter/assessment needed for your surgery?

Name:

Title:

Address:

Relationship to you:

Any other significant information that you would like me to know or include in your letter supporting you for SRS? (Initials)

Why have you chosen to have SRS at this particular time?

What effect would it have on your life, if surgery were not an option?

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)

Name:

Date:

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

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