[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-171955-105":53,"doc-detail-171955-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","ohsu-thp-letter-of-support-template-2023-clinical-assessment-and-endorsement-checklist","OHSU THP Letter of Support Template 2023 - Clinical Assessment and Endorsement Checklist","","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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ohsu-thp-letter-of-support-template-2023-clinical-assessment-and-endorsement-checklist/171955/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ohsu-thp-letter-of-support-template-2023-clinical-assessment-and-endorsement-checklist/171955.png","ImageObject",442,249,{"name":88,"@type":89},"Skyler","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-19","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be completed for the client or patient section?","Question",{"text":108,"@type":109},"The template requests client demographics such as name, legal name (if different), pronouns, date of birth, phone, and address.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which clinician details are required in this letter template?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"What post-surgery planning areas does the template cover?",{"text":117,"@type":109},"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.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},171955,1788288193,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":73},2336464648746,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Date of Letter: \u0003MM/DD/YYYY\u0004\u000bNote: this is the date the letter is finalized\nClient/Patient Demographics\nName: \u0003Client Name\u0004\n\u0003Legal name if different: \u0003Client’s Legal Name\u0004\u0004\n\u0003Pronouns: \u0003Pronoun 1/Pronoun 2\u0004\u0004\n\u0003DOB: \u0003MM/DD/YYYY\u0004\u0004\n\u0003Phone: \u0003(###)###-####\u0004\u0004\n\u0003Address:  \u0003Client’s Address\u0004\u0004\nClinician Information\n\u0003Clinician Name: \u0003Name\u0004\u0004\n\u0003Office/Agency location or clinic:  \u0003Location or Clinic\u0004\u0004\n\u0003Phone number of clinician: \u0003(###)###-####\u0004\u0004\n\u0003Clinician email address: \u0003clinician@clinic.com\u0004\u0004\n\u0003Type of license: \u0003Name of License Held\u0004\nNote: Assessments must be completed or attested to by a licensed clinician. \u0004\n\u0003Please describe your experience completing assessments for gender affirming surgeries:\n\u0003\nDescription of experience\u0004\u0004\nFor which surgery/surgeries does this letter of support endorse? Check ALL that apply\n\u0003\u0003☐\u0004 Breast augmentation\u0004\n\u0003\u0003☐\u0004 Mastectomy with chest reconstruction\u0004\n\u0003\u0003☐\u0004 Orchiectomy\u0004\n\u0003\u0003☐\u0004 Hysterectomy/Oophorectomy\u0004\n\u0003\u0003☐\u0004 Vaginoplasty/Vulvoplasty\u0004\n\u0003\u0003☐\u0004 Vaginectomy\u0004\n\u0003\u0003☐\u0004 Metoidioplasty\u0004\n\u0003\u0003☐\u0004 Phalloplasty\u0004\n\u0003\u0003☐\u0004 Facial gender confirmation\u0004\n\u0003\u0003☐\u0004 Tracheal Shave\u0004\n\u0003\u0003☐\u0004 A surgery not listed here. Please describe: \u0003description of surgery\u0004\u0004\n\u0003Please list the dates that you met with this client to complete this assessment/letter of support for gender affirming surgery:\u000b\u0003MM/DD/YYYY\u0004\u0004\n\u0003Please 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.\u000b\u0003\u000bClick or tap here to enter text\u0004\u0004\n\u0003If 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.)\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003Please describe your rationale for the referral for surgery at this time:\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003Are 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.:\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003For 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:\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003If 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:\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003\n\u000f\nDescribe 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.):\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003Does 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:.:\u000b\u0003\u000bClick or tap here to enter text.\u0004\u0004\n\u0003Please 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.\u000b\u0003\u000bList all medications\u0004\u0004\n\u0003Please 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","cbCaiiYPLnCbLxWL","https://ap.wps.com/l/cbCaiiYPLnCbLxWL","docx",133314,6,"English","# Client/Patient Information\n## Demographics and Contact Details\n# Clinician Information\n## Licensure and Assessment Experience\n# Surgery Endorsement Details\n## Endorsed Procedures\n## Assessment Meeting Dates\n# Clinical Narrative and Medical Context\n## Gender dysphoria and Hormone Response\n## Referral Rationale\n## Communication and Care Challenges\n## Expected Functional Improvements\n## Facial Gender Confirmation (if applicable)\n## Mental Health and Symptom Destabilization Risk\n## Medications\n## Substance Use and Pain/Nicotine Plans\n# Post-Surgery Planning\n## Housing After Surgery\n## Support System\n## Aftercare Capability\n## Letter Expiration and Update Plan\n## Additional Care Arrangements","[{\"question\":\"What information must be completed for the client or patient section?\",\"answer\":\"The template requests client demographics such as name, legal name (if different), pronouns, date of birth, phone, and address.\"},{\"question\":\"Which clinician details are required in this letter template?\",\"answer\":\"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.\"},{\"question\":\"What post-surgery planning areas does the template cover?\",\"answer\":\"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.\"}]","OHSU THP Letter of Support Template 2023 - Clinical Assessment and Endorsement Checklist | DOCX"]