[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-279745-105":53,"doc-detail-279745-en":127},{"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":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","sample-behavioral-health-letter-cover-letter-gender-affirmation-surgery","SAMPLE BEHAVIORAL HEALTH LETTER - Cover Letter - Gender Affirmation Surgery","","Behavioral health referral letter template for supporting a patient’s request for gender affirmation surgery such as chest reconstruction or breast augmentation. The form captures patient identity details, therapy history and evaluations, social and psychological gender identification, optional hormone therapy experience, and documented emotional distress related to gender dysphoria criteria. It includes statements about the patient’s understanding of permanence, costs, recovery time, risks, informed consent capacity, and expected adherence to pre- and post-surgical recommendations, concluding with provider contact and signature fields.",{"@graph":63,"@context":119},[64,80,102],{"@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/sample-behavioral-health-letter-cover-letter-gender-affirmation-surgery/279745/",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/sample-behavioral-health-letter-cover-letter-gender-affirmation-surgery/279745.png","ImageObject",442,249,{"name":88,"@type":89},"Miles","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information does the behavioral health letter request for the patient?","Question",{"text":109,"@type":110},"It requests the patient’s legal name and preferred name, date of birth, pronouns, identified gender, and the dates of therapy and evaluation, along with the primary care physician details when applicable.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What clinical points are included to support gender affirmation surgery?",{"text":114,"@type":110},"The letter documents social and psychological gender identification, significant emotional distress tied to gender dysphoria criteria, and states that gender affirmation surgery is the next appropriate step for the patient to live in their identified role.",{"name":116,"@type":107,"acceptedAnswer":117},"What does the letter say about the patient’s readiness and consent?",{"text":118,"@type":110},"It states the patient understands permanence, costs, recovery time, and possible complications, is capable of making an informed decision, and is reasonably expected to follow pre- and post-surgical recommendations.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},279745,1789526615,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"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":126,"read_time":4},13056703019404,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","SAMPLE BEHAVIORAL HEALTH LETTER  \n(ON LETTERHEAD)  \n( Date)  \nRe: (patient’s legal name and preferred name)  \n(Date of birth)  \nDear Dr. (name):  \nI am writing on behalf of my client (legal name, preferred name, and date of birth), who uses (pronouns), whom I would like to refer for gender affirmation surgery (chest reconstruction or breast augmentation) . (Patient preferred name) has been seeing me for therapy since (date) and was evaluated by me on (date). (Patient preferred name) is being followed for primary care by (name of physician).  \n(Patient preferred name) identifies as (gender) both socially and psychologically. (Patient preferred name) has been living (pronoun used) life fully and openly as (gender) for (x amount of time) . Patient preferred name presents full time as (identified sex/gender) .  \nIf undergoing hormone therapy include this section (if not disregard)(Patient preferred name) presents full times as (identified sex/gender) and has had a positive experience with (feminization/masculinization) through hormone therapy since (date) .  \n(Patient preferred name) continues to experience significant emotional distress due to (pronouns used) body not fully aligning with (identified gender identity) . It is my professional opinion that in this way,(patient preferred name) meets the criteria for having gender dysphoria (ICD 10: F64 . 1) and meets the Diagnostic and Statistical Manual of Mental Disorders 5 Edition criteria.  \nHaving gender affirmation (chest reconstruction or breast augmentation) surgery is the next appropriate step to enable (patient preferred name) to continue living as (gender) the role in which (pronouns used) most comfortably and effectively function.  \n(Patient preferred name) has demonstrated an understanding of the permanence, costs, recovery time, and possible complications of this surgical gender affirmation surgery and is fully capable of making an informed decision about surgery. ( Patient preferred name) is reasonably expected to follow pre and post-surgical treatment recommendations responsibility.  \nIt is my opinion that (patient preferred name) is emotionally and practically ready for this surgery provided you find (pronoun used) medically fit. It you would like to discuss this in more detail, please call me at (telephone number) .  \nSincerely,  \nPhysical signature must be included  \n(mental health provider name), (credentials)","cbCaisfDHims4j6Z","https://ap.wps.com/l/cbCaisfDHims4j6Z","pdf",89126,"English","# SAMPLE BEHAVIORAL HEALTH LETTER\n## Patient and clinician details\n## Clinical assessment and treatment history\n## Gender dysphoria criteria and surgery justification\n## Informed decision and readiness statement\n## Contact information and signature","[{\"question\":\"What information does the behavioral health letter request for the patient?\",\"answer\":\"It requests the patient’s legal name and preferred name, date of birth, pronouns, identified gender, and the dates of therapy and evaluation, along with the primary care physician details when applicable.\"},{\"question\":\"What clinical points are included to support gender affirmation surgery?\",\"answer\":\"The letter documents social and psychological gender identification, significant emotional distress tied to gender dysphoria criteria, and states that gender affirmation surgery is the next appropriate step for the patient to live in their identified role.\"},{\"question\":\"What does the letter say about the patient’s readiness and consent?\",\"answer\":\"It states the patient understands permanence, costs, recovery time, and possible complications, is capable of making an informed decision, and is reasonably expected to follow pre- and post-surgical recommendations.\"}]","SAMPLE BEHAVIORAL HEALTH LETTER - Cover Letter - Gender Affirmation Surgery | PDF"]