Informed Consent for Access to Trans Health Care
We’ve got stickers for you!
To receive a sticker (or a few) please send a self-addressed/stamped envelope to:
ICATH
1605 12th Ave STE 4
Seattle WA 98122
Not required, though much appreciated: if you are able to include a couple cash dollars it will help offset the cost (everything we do is volunteer and out-of-pocket.) Thanks!
***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:
Potential social consequences
Potential occupational consequences
Potential effects on familial relationships
Potential financial costs
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
providers for ICATHInformed Consent for Access to Trans Health Care
Dear Provider:
Thank you for working with me. As my provider you are in the position to offer me medical care that can support me to express my gender physically. I am writing this letter to request that you follow the standards of care outlined for this medication or procedure and allow us to use informed consent. I am aware of the following in regards to this gender affirming care and expect to discuss this with you in our appointment:
I am informed on the psychosocial impacts of this medical procedure and/or medication and am able to make an informed decision.
Sincerely,
ICATH 