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| Name used: |  |  |  |  |  |  |  |  |\n| Name (as appears on BC Services Card): |  |  |  |  |  |  |  |  | Pronouns: |  |  |  |  |  |\n| PHN or UCI*: |  |  | Date of birth (YYYY-MM-DD): |  |  |  |  |  |  |  |  |  |  |  Under 18yrs? |\n| Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| City: |  |  |  |  |  |  | Province: |  |  |  |  | Postal code: |  |  |\n| Phone: Voicemail ok?  Yes or  No |  |  |  |  |  |  |  |  |  | Email: |  |  |  |  |\n| Primary language: |  |  |  |  |  | Interpreter required?  Yes or  No |  |  |  |  |  |  |  |  |\n| Emergency contact name: |  |  |  |  |  | Emergency contact phone: |  |  |  |  |  |  |  |  |\n| Any considerations regarding appointment booking? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PROVIDER DETAILS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Provider name: |  |  |  |  | |  | I am the client’s\u003Cbr>primary care provider |  |  |  | MSP \\#: |  |  |  |\n| Clinical discipline: |  |  |  |  |  |  |  |  |  | Office phone: |  |  |  |  |\n| Mailing address: |  |  |  |  |  |  |  |  |  | Office fax: |  |  |  |  |\n| City: |  | Province: |  | Postal code: |  |  |  |  |  | Email: |  |  |  |  |\n| Name of client’s primary care provider: (If different) |  |  |  | Primary care provider phone: |  |  |  |  |  |  |  |  | Primary care provider fax: |  |\n| Other care providers involved (e.g., specialists, support workers, mental health team): Please list name(s), organizations, phone numbers. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| CLINICAL INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Please list the dates you met with your client to discuss hormone readiness:  Client seen via telehealth |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 1. What hormone therapy does your client wish to start? Select all that apply. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| | Estrogen-based therapy Testosterone-based therapy | |  |  |  |  |  | Puberty blockers Other: |  |  |  |  |  |  |\n\n*Individuals covered by Interim Federal Health Program (IFHP) will have a Unique Client Identifier (UCI). Providers may apply to be an Approved Provider through IFHP to bill for care delivered to IFHP-covered patients. More information can be found at the webpage“Interim Federal Health Program – Information for health care professionals in Canada“ on the Government of Canada website.  \nJune 2025 Page 1 of 6  \nHORMONE READINESS ASSESSMENT PHN OR UCI:  \n\n| 2. Please describe your client’s gender journey, their experience of gender incongruence/dysphoria, and the impact of any other gender-affirming steps taken to date (e.g., changes in hairstyle or wardrobe,\u003Cbr>padding/packing/tucking, hair removal, name change, pronoun change): |\n| --- |\n| 3. Has your client previously taken hormones, either through prescription or self-access? |\n| 4. Please summarize your client’s expectations, hopes and any concerns regarding hormone therapy: |\n\nJune 2025 Page 2 of 6  \nHORMONE READINESS ASSESSMENT PHN OR UCI:  \n\n| 5. Please describe any further gender affirming goals your client may have, either after or concurrently with hormones (e.g., specific surgeries): |  |  |\n| --- | --- | --- |\n| 6. Are there any communication or accessibility needs to be aware of? (e.g., interpreter, visual/audio aids, scentreduced space)? |  |  |\n| 7. Provide a brief description of your client’s past and current medical history, including: |  |  |\n|  | a. Physical health: List any diagnoses, treatment history and current status. |  |\n|  | b. Mental health: List any diagnoses, treatment history and current status. |  |\n|  | c. Age-specific factors for consideration: |  |\n|  | d. Current medications: Attach list if available. |  |\n|  | e. Please indicate if your client has past/current substance use that could impact their ability to start or ma","cbCairWKyk8sqNWr","https://ap.wps.com/l/cbCairWKyk8sqNWr","pdf",519419,6,"English","# Patient information\n## Provider details\n## Clinical information\n## Review of WPATH Standards of Care 8 criteria","[{\"question\":\"What patient information fields are included in the Hormone Readiness Assessment Template?\",\"answer\":\"The template collects basic identifiers such as last name, name as on the card, pronouns, PHN or UCI, date of birth, address, phone and email, primary language, interpreter needs, emergency contact details, and any considerations for appointment booking.\"},{\"question\":\"What clinical topics does the form ask the provider to document before hormone initiation?\",\"answer\":\"It asks about the client’s hormone therapy wishes, description of the gender journey and dysphoria impact, prior hormone use, expectations and concerns, further gender-affirming goals, communication and accessibility needs, and a medical history including physical and mental health diagnoses, medications, allergies, and substance use that may affect starting or maintaining hormones.\"},{\"question\":\"Which WPATH Standards of Care criteria are referenced in the review section?\",\"answer\":\"The form contains confirmation statements that potential effects and risks were reviewed, gender incongruence/dysphoria is marked and sustained, diagnostic criteria are met and other causes have been excluded, the client understands the information and has capacity to consent (including guidance for mature minors when applicable), and that decision-making capacity evaluation tools are acknowledged.\"}]","Hormone Readiness Assessment Template | PDF"]