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?*

YesNo
Email*
example@example.com
OK to email?*

YesNo
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?

MondayTuesdayWednesdayThursdayFridaySaturday
What time(s) are you available on these days?
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?

YesNo
Are you a returning or current client?*

Returning ClientCurrent ClientNeither
If you are a current CCW client, who is your primary therapist?*
Were you referred to us?

YesNo
What kind of a referral was it?

Personal referral (friend, family, neighbor, etc)Professional referral (doctor, therapist, etc)
If a professional referral, by whom?
If yes, by whom?
Are there any accessibility needs of which we should be aware?

YesNo
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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