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
Email
example@example.com
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?
Are you a returning or current client?

Returning ClientCurrent ClientNeither
Were you referred to us?

YesNo
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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