Hormone Care Intake Form

Chosen Name:

Please tell us the name you want us to call you.

Date of Birth:

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:

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?

If yes, please check all that apply:

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.)

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

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?

If yes, please check all that apply:

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?

If yes, which have you had?

0/200

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

If yes, which procedures/treatments:

9.Would you like to discuss fertility preservation with your provider (egg freezing, sperm freezing)?

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

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