Table 5.
Mental Health Assessment Questionnaire
| Therapist questions |
|---|
| What is the patient's preferred name and pronouns? |
| What is the patient's legal name, sex at birth, and gender identity? |
| Has the patient ever sought/received mental health therapy in the past? If so, when and how long were they in therapy? |
| Please describe the patient's gender journey. |
| When did they begin to explore their gender? |
| What challenges and supports have they encountered? |
| What are their hopes for affirming their gender in the future? |
| Who actively supports the patient in their gender transition? |
| For example, are there specific family members, friends, school, faith community, community groups, and professional helpers? |
| What cultural considerations may be helpful to be aware of when working with this patient, including factors that may be supportive or challenging to gender transition? |
| For example, religion, race, ethnicity, and other dimensions of diversity. |
| What are the strengths of this patient that you would like to highlight? |
| What are some potential barriers to care? |
| For example, lack of parental consent, transportation to appointment, insurance coverage, and uncertainty about desired interventions. |
| What coping skills and resources has the patient developed to address potential barriers? |
| Please describe the patient's mental health history, including how gender dysphoria may have impacted mental health. |
| For example, treatment history, recent changes, coping skills and supports, and plans to support safety. |
| Does the patient meet the criteria for a diagnosis of gender dysphoria? |
| Do you believe this patient could benefit from evaluation or resources around autism spectrum disorder? |
| If so, please elaborate. |
| What benefits do you believe the patient would experience as a result of pursuing gender-affirming medical care? |
| What, if any, concerns do you have about this patient pursuing gender-affirming medical care? |
| What recommendations would you like to share for resources and supports as this patient seeks gender-affirming medical care? |
| For example, ongoing individual therapy, consult for mental health medication, dialectical behavioral therapy group, and peer support group. |