TGNB Assessment and/or Letter Request
You requested gender affirming services through my practice (more information about me at www.wholeheartedpsych.com). *Until further notice, all services are being provided remotely due to the pandemic, for your safety and mine.*

This form is for those seeking an assessment only, not for ongoing counseling. Though I am often full for individual counseling, I am typically able to fit TGNB adults in for brief, stand-alone assessments (i.e., letters for gender affirming procedures/surgery, name change, safe travel, and/or documentation for gender/sex marker change). Please complete this form to the best of your ability. Email me if you have any questions or if you believe you received this link by mistake. megan@wholeheartedpsych.com

Note re: rates & payment - most individuals I work with use their insurance benefits depending on the plan they have. I have a document that further explains my rates and options for payment here: https://docs.google.com/document/d/1EnPCuXOJuKYtkci9QV_GOE3U0TT6p6RyeswNLr0CqI0/edit?usp=sharing
Email address *
I'm Megan (she/her) - What is your first name and pronouns? *
Please provide your cell phone number as well just in case I am unable to reach you via email. (please indicate if OK to text? if OK to leave VM?) *
In what state do you reside? Due to licensure limitations, I can only provide assessments to people who live in MA and RI.
Clear selection
1. Are you an adult seeking a gender affirming letter of referral (i.e., for surgery, name change, etc?) *
2. What kind of gender affirming letter of referral are you seeking? *
3. If seeking a letter of referral for a surgery/procedure, what is the status of your consultation with the surgeon? *
Required
3a. If you need your letter by a certain date (e.g., for the consultation, or to submit for approval for a scheduled surgery), what is that date?
3b. If seeking a letter of referral for a surgery/procedure, please tell me a bit more (if you know) about what procedure you're hoping to have, which surgeon's office you plan to work with, and if there are any concerns or questions in particular you would hope to discuss in our meeting?
4. If seeking a letter for a different reason (i.e., not for gender affirming surgery or procedure referral letter), please tell me more about how I might be able to help you and what documentation you need.
5. If I am not able to get you in within a few weeks or so for an assessment for your letter, how long would feel manageable to wait? (I acknowledge that no amount of time will necessarily feel 'comfortable' when not affirmed in your body). Regardless of the wait, I can offer suggestions to get assessed sooner. *
Required
6. What are good days/times that could work for you? Please indicate any/all possible times that generally work, as well as if your schedule allows for any flexibility. I generally see private practice clients on Monday after 5PM and Wednesdays after 4PM, but sometimes have openings on days I'm not working at my full-time 9-5 position. *
7. How were you hoping to pay for our meeting(s)? See top of this form for a link to more info about my rates & payment. *
8. If hoping to use health insurance in-network or out-of-network benefits, what insurance do you have? *Note: Make sure your insurance covers tele-mental-health appointments.*
Clear selection
9. How did you hear about about my practice? *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of wholeheartedpsych.com. Report Abuse