• The client’s general identifying characteristics (their appearance, to prevent letter swapping)
• 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

• 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.
• If the patient is nonbinary, explain their chest dysphoria or gender goals
• Narrative of symptoms
• Long-standing desire for surgery
• Note any history of depression, anxiety, self-harm, suicidality, etc.

• List steps taken to transition so far, how they have helped, and their inadequacy to resolve their gender dysphoria
• Use of binder, problems associated with it
• Describe specific examples of impairment (how they are limited presently socially, school, physically, etc.)
• Harms associated with not having or delaying surgery

• Capacity to make a fully informed decision (SOC p. 59)
• A statement about the fact that informed consent has been obtained from the patient (SOC p. 28)
• Address age-related concerns, indicate the maturity of person
• Indicate if the parents consent to and are supportive of this treatment
• Show “If significant medical or mental health concerns are present, they must be reasonably well controlled” (SOC p. 59)

• Explain that WPATH criteria for surgery (p. 59) have been met.
• Note that WPATH SOC (p. 21) do not specify a minimum age requirement for top surgery.
• If one year of testosterone and social transition have been met, note that. If not, note why that is not necessary in this case.
• 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
• Indicate if the surgery will help to alleviate the person’s gender dysphoria

• “A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.” (SOC p. 28)
• Some insurance companies require a “Treatment plan that includes ongoing follow-up and care by a qualified behavioral health provider experienced in treating gender dysphoria.” You can indicate that the patient intends to continue seeing you after surgery.

• 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
• Note any training in childhood and adolescent developmental psychopathology
• Note any specific competence in diagnosing and treating children and adolescents with gender dysphoria
• Continuing education in the assessment and treatment of gender dysphoria
• Professional associations
• Publications
• Trainings given, courses taught
• Consider attaching CV

If you need any additional information, please do not hesitate to contact me at [phone].

Sincerely,

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