Gender Health Center Surgery/Hormone Letter Sign-Up Sheet

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Please complete this form if you are interested in scheduling a letter assessment appointment in order to obtain a letter from GHC for your gender affirming surgery or hormones.

If you have any questions, please email Ari, the Director of Mental Health (ari@ghcmail.org).

Email *

What is the full name (first + last) of the person seeking a letter of support? *

If the person seeking a letter of support has a legal name that is different, feel free to share it with us:

What are the pronouns of the person seeking the letter of support? *

Phone Number we can call to set up an appointment (Put n/a if you do not have a phone) *

Date of birth of the person seeking a letter of support? *

YYYY

Are you a parent filling out this form on behalf of a minor?

Yes

Clear selection

If you are a parent filling out this form on behalf of a minor, what is your name, phone number, and email address?

If you are a minor, please provide the name, phone number, and email address for your legal caregiver.

Please note, by providing GHC with this information you are giving us permission to contact your legal caregiver.

Does the person seeking a letter of support live in California? NOTE: We cannot provide services for people outside of California. *

Yes

What county do you live in? (This question refers to the person needing the letter of support). *

Please select any identities that apply to you (this question refers to identities of the person needing the letter of support).

Black or African American

American Indian, Alaska Native, Tribal or Indigenous (excluding indigenous to Latin America)

Indigenous to Latin America (Including Mexico, Central America, and South America)

Native Hawaiian or Other Pacific Islander

Middle Eastern or North African

Asian

Hispanic or Latinx

White

Other:

If you're comfortable sharing, what is your gender identity (this question refers to identities of the person needing the letter of support)?

If your primary language is not English, let us know what your preferred language is below.

Do you require any accommodations? If so, please describe.

What procedure/care are you, or your child, seeking that requires you to obtain a letter? *

How many letters are you required to have?

Letters for gender affirming medical care are only valid for one year from the date they are written. Sometimes, the process for obtaining care takes longer than a year. In these cases, you will be required to obtain a new letter, which will require starting this process from the beginning with GHC. Please check the box below to confirm that you understand. *

Yes, I understand.

How did you hear about us?

Send me a copy of my responses.

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