I think it depends on where you live, but for me, I live in Arizona, which isn't even a liberal state but the regulations to start hormones aren't very strict actually. My therapist told me, that I could talk to the doctor on campus (University) and she would just prescribe me hormones without a letter of recommendation. I, of course wanted to be safe and asked her to write a letter just in case, which she had no issue. It also did not take 3 months of therapy for this to happen, apparently she told me that it is not a requirement exactly anymore. I guess things have been changing recently....very recently