WPATH Readiness Assessment Information Form

Background Information

Legal Name

Preferred Name

Pronouns

Sex Assigned at Birth

Gender Identity

Health Care Number

Please describe your reason for seeking a WPATH readiness assessment (e.g. HTR, surgery)

How long have you known that your gender is discrepant from your assigned sex at birth?

When did you first consider pursuing surgery and/or hormone replacement therapy? What prompted that?

Who are your social supports (e.g. family, friends, health care team)?

Mental Health History

Do you experience any mental health challenges? If yes, please describe your symptoms or challenges

Have you ever seen a mental health professional (i.e. therapy, assessment)? If yes, please explain.

Have you ever been diagnosed with a metal illness? If yes, please list the diagnoses, approximate date of diagnosis and whom the diagnosis was rendered by (e.g. family doctor, psychiatrist, psychologist)

Have you ever experienced symptoms of psychosis (e.g. delusions, hallucinations, inability to discern reality from fantasy)?

Yes No

Do you have a diagnosis of schizophrenia?

Yes No

Do you have a diagnosis of bipolar disorder?

Yes No

Do you have an intellectual disability?

Yes No

Do you struggle with thoughts of suicide?

Yes No

Do you struggle with self-harm?

Yes No

If you answered yes to any of the above, please explain.

Medical and Physical Health

Do you currently take any medication? If yes, please list the name of each medication, the dose, the purpose, the effect(s), and the date you started the medication.

Do you consume nicotine (e.g. cigarettes, vape)? If yes, please describe amount and frequency.

Do you use substances such as marijuana, alcohol, and/or other drugs? If yes, please describe amount and frequency.

Do you have any medical issues that may be important to note (e.g. allergies, diabetes, autoimmune disorders, anemia, etc.)? If yes, please describe the medical concern and treatments.

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