Gender Affirming Letter Appointment Request Form

Gender Affirming Letter Appointment Request Form

This form is for gender affirming letters for transition related medical services (i.e. gender confirming hormones or gender confirming surgeries). This does not link you with ongoing counseling services.
Legal Name

First NameLast Name
Preferred Name (if different)
Pronouns
Example: She, her, hers
Phone Number

Area CodePhone Number
OK to text?
Email
example@example.com
OK to email?
Date of Birth

MonthDayYear
Date
Appointments are scheduled based on availability. Please list your scheduling preferences below. These preferences are not a guarantee.
What days of the week are you available for your letter writing appointment?
What time(s) are you available on these days?
How many Gender Affirming Letters will you need?
What type(s) of medical transition related care do you need this letter for?
Do you specifically need a PhD clinician to write your letter?
Are you a returning or current client?
If you are a current CCW client, who is your primary therapist?
Were you referred to us?
What kind of a referral was it?
If a professional referral, by whom?
If yes, by whom?
Are there any accessibility needs of which we should be aware?
If yes, please explain.
*Assessment includes letter contingent upon meeting WPATH standards.*

Once you click the Submit button below, your information will be sent directly to our Client Care Coordinator. She will be in contact with you shortly to schedule an appointment time or gather additional information.
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