You can open the Wpath Letter For Top Surgery Template in multiple formats, including PDF, Word, and Google Docs.
Wpath Letter For Top Surgery Template Printable | Editable FormSample
Examples
[Name of the Assessing Therapist]
[Therapist’s Credentials]
[Therapist’s Address]
[Therapist’s Phone]
[Therapist’s Email]
[Name of the Patient]
[Patient’s Date of Birth]
[Patient’s Address]
[Date of the Letter]
Letter of Recommendation for Top Surgery
This letter serves as a formal recommendation for [Patient’s Name] to undergo top surgery as part of their gender-affirming treatment. This recommendation is based on the comprehensive assessment conducted during [Specific Timeframe].
[Patient’s Name] has been under my care since [Date], and their treatment has included [Specify types of therapy or assessments]. The patient has demonstrated a clear understanding of the surgical procedure and its implications.
[Provide relevant diagnoses, e.g., Gender Dysphoria, etc. and how they relate to the patient’s desire for surgery.]
The patient has been informed about the risks, benefits, and expected outcomes of top surgery. Additionally, they have shown a commitment to the surgical process and post-operative care.
I fully support [Patient’s Name]’s request for top surgery, as it aligns with the standards set forth by the World Professional Association for Transgender Health (WPATH). This procedure is anticipated to significantly improve their quality of life.
Should you have any further questions or require additional information, please do not hesitate to contact me at [Therapist’s Phone] or [Therapist’s Email].
[Signature of the Therapist]
[Name of the Therapist]
[Therapist’s Credentials]
[Name of the Assessing Therapist]
[Therapist’s Credentials]
[Therapist’s Address]
[Therapist’s Phone]
[Therapist’s Email]
[Name of the Patient]
[Patient’s Date of Birth]
[Patient’s Address]
[Date of the Letter]
Letter of Support for Top Surgery
This letter is written to provide my professional opinion regarding [Patient’s Name]’s eligibility for top surgery, following a thorough evaluation and ongoing therapeutic support.
Throughout our time together, [Patient’s Name] has expressed a consistent desire to transition socially and medically. [Include details about the patient’s mental health status and their journey toward gender affirmation.]
[Patient’s Name] has taken appropriate steps to express their gender identity, including [mention any relevant treatments, name changes, social transitions, etc.].
The patient is aware of the implications of the surgery, understands the procedural risks, and has made informed decisions regarding their health care.
In conclusion, it is my recommendation that [Patient’s Name] be approved for top surgery as it is an essential aspect of their transition and overall well-being.
For any further clarifications, please reach out to me at [Therapist’s Phone] or [Therapist’s Email].
[Signature of the Therapist]
[Name of the Therapist]
[Therapist’s Credentials]
Format
Please complete the form below to create the WPATH Letter for Top Surgery Template. All fields must be filled out to ensure a clear and comprehensive letter. We provide examples to guide you through each step. WPATH Letter for Top Surgery Template 1. Clinician Information 2. Patient Information 3. Introduction 4. Patient’s History 5. Treatment History 6. Clinical Assessment 7. Recommendations 8. Final Statement 9. Signature and Date
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WORD
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Wpath Letter For Top Surgery Template Printable | Editable FormPrintable
