Use this checklist to ensure that each element is included in your letter. Use language that is client specific; do not simply copy this checklist.
Identification of patient and diagnosis
- The client’s general identifying characteristics (age, gender, etc.)
- The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date
- Results of the client’s psychosocial assessment, including any diagnoses
Statement of Medical Necessity
- Explain that WPATH criteria for hormones have been met. (p. S258, Appendix D of WPATH SOC v8, available here) Address each point of the WPATH Criteria:
- Gender diversity/incongruence is marked and sustained over time
- Meets the diagnostic criteria of gender incongruence in situations where a diagnosis is necessary to access health care
- Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment
- Mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed; sufficiently so that gender-affirming medical treatment can be provided optimally.
- Informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility
- Reached Tanner stage 2
- Indicate you recommend initiating puberty blockers / hormone replacement therapy.
- Use the phrase “medically necessary,” which is generally defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
- Note harms associated with withholding or delaying puberty blockers / hormone replacement therapy
- If there has been involvement of parent(s)/guardian(s) in the assessment process, note that, unless their involvement is determined to be harmful to the adolescent or not feasible
State the qualifications of the provider
Discuss your credentials as applicable. Omit things that do not apply.- Education and degree
- Licensure
- Length of time & experience working with/diagnosing trans patients
- Number/percentage of trans patients seen, if a significant part of your practice
- Continuing education in the assessment and treatment of gender dysphoria;
- Relevant professional associations
- Relevant publications
- Relevant trainings given, courses taught
- Consider attaching CV if a specialist
If you need any additional information, please do not hesitate to contact me at [phone].
Sincerely,
Signature Provider’s Name Licensing information
Updated on Mar 12, 2025