***Replace all Green Font with your details***
providers for ICATHInformed Consent for Access to Trans Health Care
DATE
PROVIDER NAME
ADDRESS
ADDRESS
PHONE/FAX
Dear PROVIDER NAME:
NAME has met with a therapist/advocate regarding hormone use.
PRONOUN has discussed the following in regards to beginning hormone use:
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Potential social consequences
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Potential occupational consequences
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Potential effects on familial relationships
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Potential financial costs
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Potential impacts on mental and physical health
NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision.
Sincerely,
NAME, CREDENTIAL
Therapist/Advocate
I, NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision.
Sincerely,
NAME NAME
Patient Parent/Guardian