Hormone Therapy Doctor Questionnaire

Here’s an example of a form one of our members used in his quest to find decent service providers. Feel free to copy this and send it to potential doctors or use the questions as a guide when interviewing your doctors. Remember, it’s your journey. You get to choose who accompanies you on it!

THERAPIST QUESTIONNAIRE

YOUR NAME: ____________________________

DATE: _____________

Please answer ALL questions. If you already have a pre-existing document that addresses some or all of the questions below, you can substitute that document in lieu of fully completing this form provided that (1) you indicate which questions are addressed by the document and (2) the combination of this questionnaire and the document completely address ALL of the questions listed. Please attach additional pages as necessary.

How long have you been a physician?

What do you consider to be your area of expertise?

Have you ever provided hormone therapy for transgender patients?

If so, how many? How many were assigned female at birth or assigned male at birth?

What is your professional opinion of people who feel they are transgender? What is your personal opinion?

If so, how many? How many were assigned female at birth or assigned male at birth?

Are you practices consistent with the WPATH Standards of Care (SOC) version 7?
Do you understand how they changed in 2011?

Do you offer a “sliding fee scale?” If so, under what circumstances?

Are you a member of any Preferred Provider Network? If so, which?

Do you write referral letters to medical doctors who provide transition-related surgeries?

Have you ever worked with any transgender youth or children?

Have you ever provided puberty blockers or hormone therapy for transgender youth?

What is your professional opinion of youth who feel they are transgender? What is your personal opinion?

Thank you for completing this questionnaire. Please return it using the enclosed envelope to:

Name

Address