Hormone Care Intake Form

Hormone Care Intake Form
Chosen Name:
Please tell us the name you want us to call you.
Date of Birth:*

MonthDayYear
Date
Legal Name (Name used on insurance and id):*

Legal First NameLegal Last Name
At Family Tree Clinic, we focus our care around your individual goals. Family Tree Clinic uses an informed consent model and your answers on this form will not determine whether or not you will be prescribed hormones. Informed consent means you and your provider discuss the potential benefits, side effects, and risks of hormones and make a plan together without needing a letter from a therapist.

The following questions help your provider understand how to support your hormone care goals and guide your appointment. Feel free to skip questions that you don't understand or don't want to answer.
1a.What changes are you hoping to see from hormone therapy? You can mark by any of the listed words below and/or describe in your own words:

VoiceSkinLower bodyMenstruationMusclesOdorHead hairFat distributionGenitalsBody hairFaceFertilityFacial hairUpper bodySex driveDescribe in your own words
2. Are there any specific changes you have questions or concerns about?
3. Are there any specific side effects you have questions or concerns about?
4. Is there anyone else that you see to support your health?

YesNo
If yes, please check all that apply:

Primary Care ProviderTherapist/psychiatristSocial worker/case managerOther healthcare provider
Primary Care Provider clinic name:
Therapist/psychiatrist clinic name:
Other healthcare provider clinic name:
5. Have you worked with a mental health professional regarding gender identity? (Family Tree Clinic does not require a letter from a mental health provider or for a patient to be seeing a mental health provider to receive hormone therapy.)

YesNo
6. Are you currently taking any gender affirming hormone medications? (This could be prescribed medications or medications you bought online or shared with friends.)

YesNo
a. If yes, what are you currently taking and for how long have you been taking them?

0/200
b. Have you tried any other methods in the past?

YesNo
If yes, please check all that apply:

InjectablesPatchesPillsGels/creamsImplants
The next two questions ask about gender affirming surgeries, procedures, and treatments. Please know there are no requirements or expectations for pursuing any of these procedures. We ask these questions to allow your provider the opportunity to support your goals.
7. Have you had any gender affirming procedures/treatments?

YesNo
If yes, which have you had?

0/200
8. Are you currently considering or interested in any gender affirming procedures/treatments besides hormone therapy?

YesNo
If yes, which procedures/treatments:

Body contouringBreast augmentationChest reconstruction (top surgery)Facial feminization surgeryFacial masculinization surgeryHysterectomy or oophorectomy (removal of the uterus/ovaries)Laser hair removal or electrolysisMetoidioplasty or phalloplasty (creation of a phallus)Orchiectomy (removal of the testicles)Silicone injectionTracheal shaveVaginoplasty or vulvoplasty (creation of a vagina/vulva)Vocal therapy/coachingVocal surgeryOther
9.Would you like to discuss fertility preservation with your provider (egg freezing, sperm freezing)?

YesNoNot sure
10. Have you legally changed your name and/or gender marker or are interested in doing so?

Yes, I have legally changed my name and/or gender markerNo, and I am not interestedNo, and I am not interested
11. Is there anything else you want your provider to know about your goals related to your healthcare and hormone therapy? Do you have any other questions or concerns?

0/250
Should be Empty: