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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

"*" 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 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)

Name

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

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