Letter for Gender Affirming Surgery and Consent "*" indicates required fields Legal Name: First Middle Last Birth Name:* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:*Email:* Date of Birth:* MM slash DD slash YYYY Current Age:*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 aware of your plan to have surgery?* Yes No I do not have children What are the names and ages of your children? Is sperm banking something that you would like to do prior to surgery as a reproductive option?* Yes No If you have already donated sperm, when?* I have a good network of friends who give me emotional support, accept me and support my transition.* Yes No How many people are in your network of friends?* 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?* Second Assessment Writer's Title:* Second Assessment Writer's relationship to you:* Second Assessment Writer's Address:* Any other significant information that you would like me to know or to include in your letter supporting you for surgery?*Why have you chosen to have surgery at this particular time?*What effect would it have on your life, if surgery were not an option?*Signature*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)CommentsThis field is for validation purposes and should be left unchanged.