You can open the Wpath Letter For Hormones Template in multiple formats, including PDF, Word, and Google Docs.
Wpath Letter For Hormones Template Printable | Editable FormSample
Examples
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Provider’s Name]
[Provider’s Specialty]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
[Date of the Letter]
Letter of Support for Hormone Therapy for [Patient’s Name]
This letter serves to affirm that [Patient’s Name] has been evaluated accordingly and is seeking hormone therapy as part of their gender transition process.
The patient has undergone comprehensive psychological assessment and meets the criteria outlined in the WPATH Standards of Care, including:
1. Persistent, well-documented gender dysphoria.
2. Capacity to make informed decisions regarding treatment.
3. The ability to provide informed consent.
I recommend initiating hormone therapy with [Desired Hormones] as part of the patient’s treatment plan, starting with the following protocol: [Specify dosage and administration details].
Regular follow-up appointments will be conducted to monitor [Patient’s Name]’s response to therapy and to address any medical or psychological concerns as they arise.
I support [Patient’s Name]’s request for hormone therapy, as it is critical for their health and well-being. This treatment will significantly enhance their quality of life and align their physical appearance with their identified gender.
[Provider’s Signature]
[Provider’s Name]
[Provider’s Credentials]
[Provider’s License Number]
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Provider’s Name]
[Provider’s Specialty]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
[Date of the Letter]
Letter of Recommendation for Hormone Therapy for [Patient’s Name]
This letter is written in support of [Patient’s Name]’s request for hormone therapy following a thorough assessment.
Following an evaluation, the patient demonstrates:
1. Persistent desire to affirm gender identity.
2. A clear understanding of the effects and potential risks associated with hormone therapy.
3. A support system in place to assist during the transition process.
I recommend starting hormone therapy with [Desired Hormones] with an anticipated regimen of [Specify dosage and administration details].
The patient will have regular appointments to assess health outcomes and psychosocial well-being, including check-ins for any side effects.
Hormone therapy is a critical step for [Patient’s Name] in their gender affirmation journey. I fully endorse this treatment plan to support their mental and emotional health.
[Provider’s Signature]
[Provider’s Name]
[Provider’s Credentials]
[Provider’s License Number]
Format
Please complete the form below to create the WPATH Letter for Hormones Template. All fields must be filled out to ensure a comprehensive and effective letter. We provide examples to guide you through each step. WPATH Letter for Hormones Template 1. Patient Information 2. Provider Information 3. Diagnosis 4. Treatment Recommendation 5. Justification for Treatment 6. Informed Consent 7. Additional Recommendations 8. Provider Signature 9. Date of Letter 10. Patient Acknowledgment
PDF
WORD
Google Docs
Wpath Letter For Hormones Template Printable | Editable FormPrintable
