This is the form letter the clinic I go to uses for HRT and surgery. I would copy/paste this into a Word document, make the necessary updates so that it is right for you, and then forward to your therapist to use:
[Letter should be written on professional's stationary with address and other contact information at the top]
Date
Letter of Recommendation for (Choose One): Surgery | HRT | Other
Patient Name: Your name here
Date of Birth: Your DOB here
To Whom it May Concern:
I am writing this statement of medical necessity on behalf of [Patient's Name]. I am a licensed professional counselor currently employed by [Name of Employer], specializing in care for transgender patients located in [City, State]. In my role, I conduct psychological assessments for patients seeking hormone replacement therapy and gender confirming surgery. During these evaluations I obtain a full mental health, psychosocial, and psychiatric history in an effort to ascertain whether or not a diagnosis of Gender Dysphoria (DSM-5, 302.85, and ICD 10, F64.1) as per the DSM-5, is substantiated. This assessment is also aligned with the requirements of the World Professional Association of Transgender Health Standards of Care.
Upon completion of a thorough clinical interview it is my professional opinion that the [HRT | Specific Surgical Procedure] is medically necessary, clinically appropriate, and will significantly improve this patient's quality of life.
The following criteria for the medical necessity of [HRT | Surgery] have been met:
1. The client is of the age of consent and has the capacity to make fully informed decisions.
2. He/She/They have been diagnosed with and meet all of the criteria for the DSM-5 diagnosis of Gender Dysphoria (302.85). He/She/They exhibit all of the following diagnostic criteria:
2a. He/She/They demonstrate the desire to live and be accepted as male/female and wish to make his/her/their body as congruent as possible with his/her/their gender identity through surgery. Their gender identity has been persistently present for more than [X] years.
2b. IF SURGERY: The client is adherent to a regimen of medically supervised hormone replacement therapy. He/She/They have made a full social transition and live full time as male/female in all spheres of his/her/their personal and professional life.
2c. The disorder is not a symptom of another mental disorder.
2d. The disorder causes him/her/them clinically significant distress and impairment in social, occupational, and other important areas of functioning. The male/female features of his/her/their body are incongruent with his/her/their gender and cause him/her/them intense distress on a daily basis.
3. He/She/They present with no acute mental health concerns beyond the scope of Gender Dysphoria, is mentally stable and high functioning.
4. The client has done research and is educated in the treatment that he/she/they are seeking. His/Her/Their expectations are realistic. He/She/They have a well thought out plan including ongoing social support and medical care.
If you would like more information regarding the patient's mental health, we can provide it with his/her/their written consent. Please feel free to contact me if you are in need of futher information.
Sincerely,
Signature
Name
Title
Contact Information
Medical Licenses
