As a current BHIS client, we are available to support you through a WPATH letter writing assessment. If you are seeking assessment for puberty blockers or hormone replacement therapy, please stop filling out this form and instead fill reach out to your provider, letting them know you are interested. If you are requesting to be assessed for a secondary letter for surgery, please continue to fill out this form.

All of our Heart and Solutions therapists are trained and qualified to complete WPATH Letters of Support. Please contact your Heart and Solutions therapist to complete a WPATH letter at your next appointment. If you already have a letter of support from your therapist and you need a secondary letter, please continue to complete this form.

This form is intended for individuals who do not want ongoing therapy. If you are not certain about ongoing therapy needs, we recommend you complete our therapy intake to further discuss your mental health and transition needs with one of our gender-affirming therapists who can also write letters of support. If you would like to explore therapy needs, please stop filling out this form and submit our therapy intake request here: https://heartandsolutions.net/client-forms/referral-form/

We are happy to work with you as a Heart and Solutions therapy client! To honor your time and energy with paperwork tasks, please stop filling out this form and submit our therapy intake request here: https://heartandsolutions.net/client-forms/referral-form/. We will connect you with one of our gender-affirming therapists who can also write letters of support.

We are only able to offer WPATH letters to Iowa residents at this time. We encourage you to reach out to your nearest LGBTQ+ organization for guidance on connecting to therapists who can provide letters of support

Our letter writing service is intended for community members who are ready to move forward with a medical transition procedure or treatment and whose provider requires a letter of support. Some providers do not require these letters and some have specific requirements that need to be assessed for by a mental health provider.

To ensure these appointments are available to people who need them and to reduce time-related barriers in accessing transition-related care, we recommend that you find a medical provider, confirm an appointment, and confirm what their specific requirements are for letters of support prior to requesting an assessment for a letter.

To find a gender-affirming medical provider, see One Iowa’s Health & Wellness resource list here: https://oneiowa.org/resources/health-wellness/. If you would like to explore therapy needs while experiencing gender dysphoria or other mental health concerns, please submit our therapy intake request here: https://heartandsolutions.net/client-forms/referral-form/ 

Legal name is required within the WPATH letter for insurnace verification. This name will be used in the letter as "Chosen Name (Legal Name) Last Name" in the initial statements with all further referrals being "Chosen Name."

Legal sex is required for identity verification and assessment for gender dysphoria. It will be noted in the letter.

For requesters under the age of 18, all legal guardians will need to be present and sign the consent at the end of this form. 

Letters of support may or may not be required from your medical provider. Please speak with your medical provider about their requirements before completing this form. If you need support in navigating gender-affirming care options out-of-state, please view this resource from One Iowa: https://oneiowa.org/resources/medicalcareban/

Please complete the following information in regards to the Parent(s)/Guardian(s)

As a non-parental legal guardian, please upload documentation defining your guardianship of the requester. 

We value requester experiences and autonomy in understanding your lived experiences, so ask that you share information to assist in the purpose of assessment and letter-writing. Responses to these questions are generally optional to share here, but will be asked in your assessment and may be required for your letter-writing. Required questions are marked. Your therapist may ask more detailed questions about your responses in your assessment.

We recommend that you contact your doctor’s office prior to your WPATH letter assessment to ask about any details that must be documented in a letter of support. This step will help avoid time-related delays in your care.

We value requester experiences and autonomy in understanding your lived experiences, so ask that you share information to assist in the purpose of assessment and letter-writing. Responses to these questions are generally optional to share here, but will be asked in your assessment and may be required for your letter-writing. Required questions are marked. Your therapist may ask more detailed questions about your responses in your assessment.

Due to evidence on complications with surgical procedures, smoking cessation may be required for gender-affirming surgical procedures.

We encourage you to discuss with with your medical practitioner prior to the letter writting session.

I authorize Heart and Solutions to send me text messages and or to call my phone number and leave a message to remind me of my counseling appointment. I understand that these reminders will only state the name of the letter writer, the date and time of your appointment and will not disclose the nature of your appointment. Reminders will be sent out through an automated system the day before a scheduled appointment. The appointment must be scheduled at least 48 hours in advance for reminders to be sent out. I understand that Heart and Solutions is not responsible for the confidentiality of the appointment reminder once it is distributed to your voicemail or to your mobile phone. I agree that I have authorization to request reminders to the telephone number listed below. I understand that it is my responsibility to inform Heart and Solutions if my telephone number changes and I would like to continue to receive reminders.

At this time our system is only able to send reminders via text OR phone call to a single phone number.

You may choose to set up both a phone reminder AND an email reminder at the same time.

To process your request for a WPATH letter, we require a completed Release of Information (ROI) form. This ROI must be directed to the agency or healthcare provider from whom you are requesting the letter (ex: PCP providing gender-affirming care, endocrinologist for HRT, or surgeon). Failure to provide a valid ROI may result in delays or the inability to fulfill your request.

By consenting to this release, I acknowledge that Heart and Solutions, LLC will send a copy of this ROI to the provider below. No additional information or records will be released without my verbal consent.

I authorize Heart and Solutions, LLC to release information to and obtain information from:

I understand that my health information is protected under the federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. part 2, that re-disclosure is prohibited, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer will be protected by the HIPAA Privacy Law.

This form has been fully explained and I certify that I understand its contents. I understand that Heart and Solutions, LLC may not condition treatment on obtaining this consent/authorization from me.

*Jotform acts as a witness signature for this document.

This document was last updated on 1/22/2025

Welcome to Heart and Solutions, LLC: A Strength Based Counseling Agency. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and WPATH letter requester rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future. 

Appointment requests will be reviewed and assigned to therapists based on availability. Appointments are scheduled for up to 60 minutes and are typically conducted over telehealth.

The time scheduled for your appointments is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with 24 hours notice by texting or calling your WPATH letter writer. If it is possible, your WPATH letter writer will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. If you are late beyond 15 minutes, your WPATH letter writer may not have enough time to complete the letter and reserves the right to cancel the session as a late cancel. Heart and Solutions team members reserve the right to end a session, phone call, or services if they feel unsafe in any way.

If you do not attend your scheduled session and provide less than 24 hours notice once, it will be considered a late cancel. You will be offered one reschedule for a late cancel per gender-affirming procedure letter request. If you miss two scheduled appointments without communicating proactively to your WPATH letter writer, we will refer you to outside WPATH letter writers for resources. This policy ensures that the service we provide can be accessed by community members and canceled time slots may be offered to others who may benefit from this service.

Heart and Solutions’ WPATH letter writers may not be immediately available by telephone, are not crisis intervention workers, and are not on call outside of work hours. You are welcome to leave a message on their confidential voicemail and your call will be returned at their earliest convenience. If you feel you cannot wait for them to return your call or if you feel unable to keep yourself safe, 1) Call 911 and ask to speak to the mental health worker on call, 2) Go to your local hospital Emergency Room. Your letter writer will make every attempt to inform you in advance of planned absences, and will provide you with the name and phone number of the mental health professional covering their practice when applicable. Heart and Solutions team members do not engage with their requesters on social media.

Heart and Solutions and its letter writers will not confirm or deny knowledge of you as a letter requester without your written consent. If you see your letter writer outside of the session, your WPATH letter writer will not acknowledge you unless you acknowledge them first. If you have a dual relationship with your letter writer or with another Heart and Solutions team member, please disclose this as soon as possible to your letter writer so that accommodations can be made.

Heart and Solutions may use or disclose records or other information about you without your consent or authorization in the following circumstances.

Emergency: If you are involved in a serious or life-threatening emergency and we cannot ask your permission, we will share information if we believe it will be helpful to you or others.

Consultation with Our Attorney: We reserve the right to consult with our attorney at any time. Our attorney is held to standards of confidentiality and is legally required to maintain confidentiality.

Child and Dependent Adult Abuse Reporting: If we have reason to suspect that a child or a dependent adult is abused, exploited, or neglected, we are required by law to report the matter within 24 hours to the Iowa Department of Human Services.

Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization or a judge issues a court order. If we receive a subpoena for records or testimony, we will notify you so that you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, we are required to place these records in a sealed envelope and provide them to the Clerk of Court. If you, as a minor or adult, become a party in a civil commitment hearing, we may be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, and/or a law enforcement officer.

Threat to Health or Safety: If your WPATH letter writer is engaged in their professional duties and you communicate to them a specific and immediate threat to cause serious bodily injury or death, to an identified or identifiable person, and they believe you have the intent and ability to carry out that threat immediately or imminently, your WPATH letter writer is legally required to take steps to protect third parties. These precautions may include:

1. Warning the potential victim(s) or the parent or guardian of the potential victim(s) if under 18.
2. Notifying a law enforcement officer, and/or
3. Seeking your hospitalization

We will also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. Heart and Solutions team members reserve the right to end a session if they feel unsafe in any way. Additionally, by signing this document, you agree that if any member of your session does not conduct themselves in a respectful manner to any team member, confidentiality rights are waived and the police will be contacted. Should a requester or any of their support members verbally abuse a member of the Heart and Solutions team or act physically or verbally aggressive toward anyone in a Heart and Solutions office or session, they will be asked to leave the premises. If they refuse to leave the premises, confidentiality is waived and the police will be contacted. Should a team member be physically injured by another person in session, in the office or while performing their work duties, we reserve the right to file appropriate legal and or civil charges.

Insurance: While this service does not require insurance coverage, the letter will be provided to your medical provider and may be reviewed as documentation for insurance coverage for your procedure. You should also be aware that most insurance companies require you to authorize your provider to provide them with a clinical diagnosis. Sometimes letter writers have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record. This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it after they receive it. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it in writing. By signing this Agreement, you give Heart and Solutions, LLC permission to provide requested information to your carrier if you plan to utilize insurance coverage for gender-affirming medical care.

Supervision: All Heart and Solutions Behavioral Health Intervention Service letter writers have their Bachelor's degree in a Human Services related field or their Bachelor's degree in another field with at least two years of Human Service experience. All Heart and Solutions therapists are Master's level clinicians who are licensed to practice in the state of Iowa. Temporarily Licensed Mental Health Counselors, Temporarily Licensed Marriage and Family Counselors, and Licensed Master's Level Social Workers require ongoing supervision in order to reach full licensure status. This supervision is provided by a qualified supervisor within the agency or a contracted third party supervisor. To ensure quality requester care and services, requester diagnoses, assessments, and notes may be shared and discussed with this supervisor. The supervisor is ethically responsible to maintain requester confidentiality in the same manner as any Heart and Solutions team member.

Parents and Minors: While privacy in services is crucial to successful progress, parental involvement can also be essential. It is Heart and Solutions’ policy not to provide treatment to a child under age 13 unless they agree that we can share any clinically necessary information with a parent. For children 14 and older, we request an agreement between the requester and the parents allowing us to share general information about treatment progress and attendance, as well as a treatment summary upon completion of the counseling services. All other communication will require the child’s agreement, unless we believe there is a safety concern (see also above section on Confidentiality for exceptions), in which case we will make every effort to notify the child of our intention to disclose information ahead of time. In this situation, we will make every effort to handle any objections that are raised, but will be required to break confidentiality even if objections persist. We will not release any information to parents or guardians if it will jeopardize the physical or mental well being or safety of the requester. We reserve the right to deny access to records and clinical information to parents and guardians of minors if sharing the information is not in the best interest of the requester.

Release of Information to Medical Provider: To protect requester privacy and comply with HIPPA, we cannot provide this letter to your medical provider without a release of information on file. You are responsible for confirming the accuracy of information on the release of information. If you have signed a release for us to share information with your primary care doctor, the letter will be faxed or mailed to these providers in an effort to collaborate and provide a more holistic approach to your treatment. 

Communication Methods: Heart and Solutions team members may utilize cellular phone services such as, but not limited to: Verizon, AT&T, TMobile and US Cellular. Heart and Solutions team members may utilize an internet or wifi based service such as Google Voice for phone calls and text messages. Heart and Solutions team members additionally utilize Google Suites for Gmail communication. Heart and Solutions is not responsible for the confidentiality of text messages, voice calls, emails, or voicemails sent to the intended recipient utilizing the contact information provided.

Professional Records: Heart and Solutions letter writers are required to keep appropriate records of the services that we provide. Your records are maintained utilizing an electronic system called Valant. In signing this agreement, you consent to your service records being housed in Valant. We keep records noting that you were here, your reasons for seeking letter writing services, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records we receive from other providers, copies of records we send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Due to the fact that these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your WPATH letter writer or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your records, you have a right to have the decision reviewed by another mental health professional, which we will discuss with you upon your request.

Heart and Solutions requesters, and guardians of requesters, have access to all non-restricted requester records and documentation authored by Heart and Solutions, LLC. Restricted requester records include but are not limited to any and all second hand information such as documents from other agencies and collaborative services involving third parties. Records will also be considered restricted if access to them will cause harm or risk of harm to the physical or mental well being of the requester.

Collaborating agencies must request documentation in writing and provide appropriate releases of information. Heart and Solutions will release requested information only when a completed release is on file and the requester has been notified and has given consent.

You have the right to considerate, safe, and respectful care without discrimination of race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of the counseling process and about your letter writer’s specific training and experience. You have the right to expect that your letter writer will not have social or sexual relationships with letter requesters or with former letter requesters and will uphold the ethical codes of the American Counseling Association, the American Association for Marriage and Family Therapy, and the National Association of Social Workers.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your protected health information. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. If you ask us to disclose information to another party, you may request that we limit the information we disclose.

Right to Receive Confidential Communication by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of Protected Health Information by alternative means and at alternative locations (for example, you may not want a family member to know that you are in treatment). Upon your request, we will send your bills to another address. You may also request that we contact you only at work, or that we do not leave voicemail messages. To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

Right to a Copy of this Notice: Once completed, this letter request in its intirety will be emailed to you at the emal address provided. You have the right to a paper copy of this notice. You may ask your letter writer to give you a copy of this notice at any time. Heart and Solutions, LLC reserves the right to change policies and/or to change this notice, and to make the changed notice effective for medical information already accrued as well as any information received in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. We will also have copies of the current notice available via request.

Complaints and Grievances: If you believe your privacy rights have been violated or you have a concern with the quality of your treatment, you may file a complaint. To do this, please complete this form: https://heartandsolutions.net/client-forms/grievances/. You may also send a written complaint to the U.S. Department of Health and Human Services.

Compliments and Suggestions: We welcome and appreciate your compliments and suggestions! Please complete this form: https://heartandsolutions.net/client-forms/suggestions/ or contact us at 800-531-4236 or by email at help@heartandsolutions.net.

My signature below indicates that I have read, understand, and agree to the terms of the Heart and Solutions Consent to Treatment including privacy practices, WPATH letter requester rights, and WPATH letter requester financial responsibility. By signing this document, I am providing consent to be treated by Heart and Solution for outpatient therapy and/or Behavioral Health Intervention Services. I understand that insurance billing is provided as a courtesy and that I am financially responsible to Heart and Solutions, LLC for all charges resulting from my treatment. It is my responsibility to notify Heart and Solutions, LLC of any changes in my health care coverage. While Heart and Solutions, LLC verifies my insurance eligibility, exact benefits cannot be determined until the insurance plan receives the claim. I agree to accept financial responsibility for all services received by me or by my dependents. I authorize direct payment from my health insurance plan to Heart and Solutions, LLC for all services provided to me or my dependent. This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. We have discussed the privacy practices, and I understand that I may request a copy at any time in the future. I consent to accept these policies as a condition of receiving mental health services.