Gender Dysphoria Program
Date____________________
This application form must be accompanied by a recent photograph which will
remain a permanent part of your medical record. Without a photograph, your
file will not be considered complete.
Name (currently used) _________________________________
Name (legal) ______________________________________
Social security no._____________________ Date of birth______________
Address ___________________________________________________________
(No.) (Street) (City) (State) (Zip)
Phone (Home) ________________________(Work)_______________________
(Area code) (No.) (Area code) (No.)
Height ___________________________ Weight ________________________
Gender of choice: Male Female
Anatomic sex: Male Female
I dress exclusively as a: Male Female
I have lived exclusively as a _________ for __________ months.
Hormones: (Type, Dose, Frequency, How long)
Prescribing Physician (name) __________________________________
_________________________________
(No.) (Street) (City) (State) (Zip)
Person referring you to gender dysphoria program ________________
Have you ever been evaluated by another gender program? Yes No
If yes, please list the centers indicating the dates of treatment and
the reasons you left that program.
Please briefly describe what you think your problem is.
Please comment on your understanding of the therapy "program" and how
you think we can help you.
Please write a one page autobiography describing those events in
your life which you feel were most important in contributing to
your development and your current feelings about yourself.
FAMILY AND PERSONAL HISTORY
Mother (Name)
(Address)
(Occupation)
Father (Name)
(Address)
(Occupation)
Were your parents divorced? Yes No
Your age at time of divorce __
Who brought you up? (Indicate relationship) _______________________
Please list the names, ages and sex of all your brothers and sisters in order of birth.
Brefly describe what it was like for you growing up in your family,
e.g., to whom were you closest, who were your parents' favorites,
with whom did you fight most often, with whom did you get along,
who understood you the best, which parent had the most influence, etc.
What was the overall atmosphere in your family?
Did you ever feel rejected by anyone in your family? By whom?
Briefly comment on the frequency with which you communicate with your parents.
Do your parents know about your decision to cross-live? Yes No
If yes, how do your parents feel about your desire to cross-live and
to undergo sex reassignmentr surgery?
If your parents do not know, please indicate when and how you plan
to tell them.
What is your best guess as to their reaction?
Have you or any member of your family ever been in psychotherapy?
Please indicate who and for how long.
Have you or any member of your family ever been hospitalized for
psychiatric reasons. Indicate who and for how long.
Is there a history of heavy drinking in your family? Yes No
If yes, please briefly describe who had the problem and indicate
how you feel this drinking affected you.
EMPLOYMENT AND EDUCATION HISTORY
Current occupation
Employer
Length of time employed Salary
Briefly describe your feelings about this job.
I am employed as a Male Female
My co-workers consdier me Male Female
If you have not yet begun cross-living, what are your vocational
plans when you do make the change?
Assuming that five years from now you will be gainfully employed,
please state the occupation you would *most like to be in.*
Please be specific.
What occupation do you think you *will actually be in* five years
from now?
Given that this is your future employment goal, how do you plan
to accomplish it?
Please list the jobs or positions that you have held over the past
five years, beginning with your most recent job (Employer, Position, Dates Employed).
Are you on welfare? Yes No
If yes, for how long?
Have you been on welfare in the past? Yes No
If yes, for how long?
Age entered school ____ Number schools attended ___ Highest grade ___
Describe what it was like for you in high school both in terms of
your grades and academic accomplishments as well as your social life.
SOCIAL AND PSYCHOLOGICAL HISTORY
Have you ever served in the Armed Forces? Yes No
If yes, were you __ Drafted __ Enlisted
What made you decide to join the military?
Did the military experience live up to your expectations?
Did you have any significant relationships while in the service.
Briefly describe.
Under what conditions did you leave the military?
If you did not serve, please indicate how you avoided military
duty and why.
Have you experienced any harassment by law enforcement agencies.
If yes, briefly describe.
What, if any, problems with the legal system do you anticipate as a
result of your decision to cross-live?
Have you ever been involved in the use of drugs? Yes No
Please indicate which drugs you have used and the frequency of use:
Casual Frequent Addicted
Marijuana ____ ____ ____
Barbiturates ____ ____ ____
Amphetamines ____ ____ ____
Hallucinogens ____ ____ ____
Please list your current medications and the conditions for which
they are prescribed.
Have you ever attempted suicide? Yes No
If yes, please list the attempt(s) indicating your age at the
time of the attempt(s) and the method you used.
Have you ever seriously considered suicide or other self-destructive acts?
Yes No
If yes, please briefly describe.
Have you ever thought about committing suicide or other self-destructive acts?
Yes No If yes, please briefly describe.
Have you ever attempted genital injury? Yes No
Are you currently married? Yes No
If yes, are you married as a Man Woman
Briefly describe what your spouse thinks about your plans for
sex reassignement.
Please list your marriages, indicating your age at the time of marriage,
length of marriage, your gender role and whether you are now legally
divorced. the reasons for divorce should also be noted.
Have you ever parented an children? Yes No
If yes, plase list indicating name, ages, sex and with whom they live.
Please describe your current relationship with your children
and the frequency with which you see them.
Describe your children's reaction to your gender problem.
If they are not aware of your plans, how do you propose to tell them
and how do you plan to relate to them after making the change?
Please indicate your religious affiliation in childhood ______________
currently ______________
Briefly describe what your religion meant to you growing up and
what role it currently plays in your life.
What do you think your church's attitude is toward persons who
cross-live? Toward sex reassignment surgery?
Describe a typoical week's activities for you.
With whom do you live?
Do any of your friends know of your plans? Yes No
If yes, what has been their reaction?
Do you have any friends or acquaintances who are transsexuals? Yes No
SEXUAL AND GENDERAL HISTORY
Describe your parents' attitudes towards sex.
How did you find out about sexual behavior?
What were your earliest fantasies about sex?
Describe in detail your first sexual encounter with a male,
indicating what fantasies were associated with that encounter.
Describe in detail your first sexual encounter with a female,
indicating what fantasies were associated with that encounter.
In general, how important a part does sex play in your life?
When did you first experience orgasm and how was this achieved
(e.g., masturbation, with a male or with a female, etc.)
How many stable (three months or longer) sex partners have you had?
Have you ever been a prosititute?
Write a brief history of your sexual contacts, including both male
and female partners. Please indicate what was pleasurable about
these contacts and what was not pleasurable or not comfortable
about them.
Does your current sexual activity involve your genitalia?
Describe your preferred method of sexual contact (e.g., preferred
partner; type of sexual contact; degree of activity; associated
fantasy, etc.)
What do you understand the term "transvestite" to mean?
What are your feelings about transvestitism?
What do you understand the term "transsexual" to mean?
What are your feelings about transsexualism?
What do you understand the term "homosexual" to mean?
What are your feelings about homosexuality?
Age at which you first cross-dressed in public in private.
Please describe briefly the nature and frequency of your
cross-dressing and your feelings when you are so attired.
How do you currently dress? as a man as a woman
Have you ever attempted to live exlusively in the role of choice? Yes No
If yes, please indicate the length of time and the degree of success
you experienced in passing.
Have you undergone any surgical procedures to assist passing? Yes No
If yes, please indicate which operations.
Please indicate what operations you plan in the future to assist
adjustment to the role of choice.
Have you had any hormonal therapy? Yes No
As a result of the hormones, I have noticed these changes *male to female*:
As a result of hormones, I have noticed these changes *female to male*:
Why do you want sex reassignment surgery?
What differences do you feel surgery will make in your life?
What does it mean to you to be woman? (everyone should answer both
this question and the following one.)
What does it mean to you to be a man? (Please answer both
this question and the preceding one regardless of your gender of choice.)
What do you feel is the most significant difference between
being a man and being a woman?
Please rank order all of the reasons listed below in terms of
their importance to you in seeking sex reassigment surgery.
*Male to Female*
__ sexual function __ legal identity
__ social acceptance __ job or vocational success
__ improved marital relationship __ feel more complete as a woman
__ feel more complete as a female
*Female to Male*
__ sexual function __ legal identity
__ social acceptance __ job or vocational success
__ improved marital relationship __ standing to urinate
__ feel more complete as a man __ feel more complete as a male
After surgery, what do you anticipate your life style will be?
What is your understanding and reaction to possible complications
and/or discomfort involved in surgery?
Which of your qualities, characteristics and experiences do you
feel make you a particularly good candidate for surgery?
What kind of adjustments do you think you would have to make
after surgery?
Can you anticipate any problems?
You are required to list at least three persons (family and friends),
their addresses and telephone numbers. these should be persons
who always know your whereabouts and/or how to contact you in the
future. Please list their names, addresses and telephone numbers.
Name _________________________________________________ Phone ____________
Address _________________________________________________________________
Name _________________________________________________ Phone ____________
Address _________________________________________________________________
Name _________________________________________________ Phone ____________
Address _________________________________________________________________
List all professional persons who have been involved in your efforts
to cross-live.
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