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 your full name (first + last) that you use? *

If you have a legal name that is different from your name, feel free to share it with us:

Pronouns? *

Phone Number? (Put n/a if you do not have a phone) *

Date of birth? *

YYYY

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.

Do you live in California? NOTE: We cannot provide services for people outside of California. *

Yes

What county do you live in? *

If you're comfortable sharing, please select the identities that apply to you.

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?

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 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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