OHSU THP Letter of Support Template 2023 - Clinical Assessment and Endorsement Checklist

Sep 1, 2026

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Template for clinicians to document client/patient demographics and provide a structured letter of support for gender affirming surgery referrals. Collects license and experience with gender affirming assessments, the specific surgeries endorsed, dates of assessment meetings, and details of gender dysphoria history. Includes sections for hormone therapy response, referral rationale, communication and care challenges, functional improvements described in the client’s words, substance use and nicotine cessation plans, and post-surgery housing and support system arrangements, plus aftercare capability and letter update plans.

LanguageEnglish

CategoryLetters

FormatDOCX

Pages6

Reading Time2 min

AccessFree to download

Client/Patient Information

Demographics and Contact Details

Clinician Information

Licensure and Assessment Experience

Surgery Endorsement Details

Endorsed Procedures

Assessment Meeting Dates

Clinical Narrative and Medical Context

Gender dysphoria and Hormone Response

Referral Rationale

Communication and Care Challenges

Expected Functional Improvements

Facial Gender Confirmation (if applicable)

Mental Health and Symptom Destabilization Risk

Medications

Substance Use and Pain/Nicotine Plans

Post-Surgery Planning

Housing After Surgery

Support System

Aftercare Capability

Letter Expiration and Update Plan

Additional Care Arrangements

Date of Letter: MM/DD/YYYYNote: this is the date the letter is finalized Client/Patient Demographics Name: Client Name Legal name if different: Client’s Legal Name Pronouns: Pronoun 1/Pronoun 2 DOB: MM/DD/YYYY Phone: (###)###-#### Address: Client’s Address Clinician Information Clinician Name: Name Office/Agency location or clinic: Location or Clinic Phone number of clinician: (###)###-#### Clinician email address: clinician@clinic.com Type of license: Name of License Held Note: Assessments must be completed or attested to by a licensed clinician. Please describe your experience completing assessments for gender affirming surgeries: Description of experience For which surgery/surgeries does this letter of support endorse? Check ALL that apply ☐ Breast augmentation ☐ Mastectomy with chest reconstruction ☐ Orchiectomy ☐ Hysterectomy/Oophorectomy ☐ Vaginoplasty/Vulvoplasty ☐ Vaginectomy ☐ Metoidioplasty ☐ Phalloplasty ☐ Facial gender confirmation ☐ Tracheal Shave ☐ A surgery not listed here. Please describe: description of surgery Please list the dates that you met with this client to complete this assessment/letter of support for gender affirming surgery:MM/DD/YYYY Please give a description of this client, identifying characteristics, age, ethnicity, language, gender identity, etc., and their history of gender dysphoria and emphasize their attempts to address their gender dysphoria.Click or tap here to enter text If your client is taking gender affirming hormone therapy, please indicate the length of time your client has taken hormones. How do they describe their response to hormones? (e.g., decreased dysphoria, could not tolerate them, etc.)Click or tap here to enter text. Please describe your rationale for the referral for surgery at this time:Click or tap here to enter text. Are there challenges the surgeon(s) and care team need to know about regarding communication? These could include English fluency, hearing impairments, autism spectrum, literacy level, learning differences, etc.:Click or tap here to enter text. For each surgery your client is requesting, please describe how each surgery will improve your client's functioning. How will it make their life better? Please use the client's words:Click or tap here to enter text. If client is referred for facial gender confirmation, please specify any concurrent mental health diagnoses, symptoms, and how dysphoria related to their facial features affects their daily life. Please include what mental health care attempts have been made to remedy facial dysphoria. Please use client’s words and be very specific:Click or tap here to enter text. Describe how your client has approached educating themselves about the surgery/surgeries they are seeking (e.g., spoke with peers, reviewed patient education booklets, internet research, prior consult with a surgeon, explanation by PCP, etc.):Click or tap here to enter text. Does your client have a mental health diagnosis or history that the stress of surgery, anesthesia, or recovery that may cause your client to have an exacerbation of symptoms or become destabilized? For instance: PTSD, anxiety disorders, depression, bipolar disorder, schizophrenia, substance abuse, etc. If yes, please describe how you have prepared your client for this possibility and how this will be addressed:.:Click or tap here to enter text. Please list all medications that the client is currently taking related to psychological concerns, sleep, or emotional problems (this should include supplements, like St. John's Wort and medical marijuana). Please list the prescriber’s name next to the medication.List all medications Please describe current and past substance use, including nicotine. Please list any concerns you or the client has regarding their substance use or their sobriety and any implications of using

FAQs

What information must be completed for the client or patient section?

The template requests client demographics such as name, legal name (if different), pronouns, date of birth, phone, and address.

Which clinician details are required in this letter template?

It collects clinician name, office/clinic location, phone and email, type of license held, and requires that assessments are completed or attested to by a licensed clinician.

What post-surgery planning areas does the template cover?

It asks about housing after surgery, the support system during recovery, the client’s ability to carry out the aftercare plan, plans for updating the letter if it expires, and any additional care that may be needed.

Sep 1, 2026

Upload by Skyler