Here’s an example of a form one of our members used in his quest to find decent service providers. Feel free to copy this and send it to potential doctors or use the questions as a guide when interviewing your doctors.Remember, it’s your journey. You get to choose who accompanies you on it!

THERAPIST QUESTIONNAIRE

YOUR NAME: ____________________________

DATE: _____________

Please answer ALL questions. If you already have a pre-existing document that addresses some or all of
the questions below, you can substitute that document in lieu of fully completing this form provided that
(1) you indicate which questions are addressed by the document and (2) the combination of this questionnaire
and the document completely address ALL of the questions listed. Please attach additional pages as necessary.

  1. How long have you been a practicing therapist?
  2. What is your educational background? Please be specific.
  3. What is your clinical background? Please be specific.
  4. What do you consider to be your area of expertise?
  5. What is your general approach to therapy?
  6. What do you feel are the goals of therapy?
  7. What is your hourly rate? How long are your session times?
  8. Do you offer a “sliding fee scale?” If so, under what circumstances?
  9. Are you a member of any Preferred Provider Network? If so, which?
  10. Are you familiar with the HBIGDA Standards of Care (SOC)? If so, for how long?
  11. Have you ever counseled any transgendered patients? If so, how many? How many were female-to-male? During what period of time have you counseled such individuals?
  12. Have you ever diagnosed anyone with Gender Identity Disorder (GID) or Gender Dysphoria? If yes, how many times?
  13. Have you ever made a recommendation to a physician that it would be in the best interest of your patient to receive hormonal therapy (for diagnosed GID or otherwise)? If yes, how many times?
  14. Have you ever made a recommendation to a physician that it would be in the best interest of your patient to receive surgical treatment (for diagnosed GID or otherwise)? If yes, how many times?
  15. What percentage of your transgendered patients have actually completed transitioning to their “gender of choice?”
  16. On average, how long were your transgendered patients in a therapist-patient therapeutic relationship with you?
  17. Do you consider yourself a qualified “clinical behavioral scientist” as that term is defined
    under the HBIGDA SOC? If so, please state why you feel you are qualified.
  18. What is your professional opinion of people who feel they are transgendered? What is your personal
    opinion?
  19. Please list two colleagues in your field who are familiar with your work who can serve as professional
    references (i.e., individuals who can vouch for your competency, integrity, reputation, etc.). Please list
    a contact name, credentials, address, and phone number for each.
  20. Please list any comments you may have here:

Thank you for completing this questionnaire. Please return it using the enclosed envelope to:

Name

Address