Gender-Affirming Care Callback Request Form Template

It is designed for clinics, surgeons, hormone therapy providers, voice therapists, and community health centers that offer gender-affirming services. It works well as the first step on a new patient page, before a scheduled consultation.

The legal name may be needed to match insurance and medical records, while the preferred name is what your staff should use on the call. Make sure whoever returns the call sees the preferred name and pronouns first.

Patients first say whether they have a mental health support letter. Those who answer yes are asked whether the letter is ready, in progress, or not needed, and those who answer no are asked whether they would like referrals to mental health providers who specialize in gender-affirming care.

Patients who say they have insurance are asked for their provider and whether they have confirmed that gender-affirming care is covered. That lets your billing or intake team prepare for the call, and the separate self-pay question covers patients who would rather pay directly.

Yes. Edit the services list to match what your practice offers, and remove anything you refer out. If you only provide one type of care, you can replace the multi-select with a short description of your services in a text block.

Responses include health-related details, so limit access to the staff who return calls and handle intake. Check your obligations under the health privacy laws that apply to your practice, such as HIPAA in the United States, and add a short note on the form explaining how you keep information confidential.

Preferred name, pronouns, journey stage, timing, insurance details, and the open questions box are optional. Name, date of birth, contact details, contact preferences, services, and the two yes or no questions are required, and you can relax any of these to suit your intake process.