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 the procedure and diagnosis
- The client’s general identifying characteristics
- 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
- Procedure needed
Narrative account of gender dysphoria
- Show “Persistent, well-documented gender dysphoria” (SOC p. 59)
- Narrative of the person’s trans history, including hormone use. If no hormone use, explain why that is clinically appropriate for that person.
- Narrative of gender dysphoria symptoms
- Note any history of gender-related depression, anxiety, self-harm, suicidality, etc.
Comment on facial-hair-specific symptoms you are aware of such as
- Dysphoria specifically related to the facial hair
- Using makeup to hide beard shadow
- Describe specific examples of impairment due to the facial hair (how they are limited presently socially, school, physically, etc.)
Capacity to make a fully informed decision and to consent for treatment
- Patient has capacity to make a fully informed decision
- Patient has provided informed consent for hair removal
Statement of medical necessity
- Indicate if you recommend permanent hair removal
- If you find it to be accurate, use the phrase “medically necessary,” which is defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
- That hair removal is performed to treat gender dysphoria
- Indicate if hair removal will help to alleviate the person’s gender dysphoria
State the qualifications of the providerDiscuss your credentials as applicable. Omit things that do not apply.
- Education and degree
- 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].
Signature Provider’s Name Licensing information
Updated on Nov 20, 2020