Date:
Patient:
MRN:
Clincian: (Therapist, Psychiatrist specializing in Gender Dysphoria)
Reason for Visit:
Follow-up for gender dysphoria
Evaluation of symptoms and well-being
Discussion of treatment goals and progress
Review of social transition, if applicable
History of Present Illness:
Briefly describe the patient’s experience with gender dysphoria:
Duration and nature of symptoms (gender incongruence, distress related to assigned gender at birth)
Specific aspects of gender dysphoria (social dysphoria, body dysphoria)
Impact of gender dysphoria on daily life, emotional well-being, and relationships
Past Medical History:
Mental health history (depression, anxiety) – may co-occur with gender dysphoria
Medical conditions relevant to treatment considerations (e.g., hormone therapy)
Social History:
Gender identity and expression
Support system (family, friends, partners) and their understanding of gender identity
Social transition steps taken (e.g., name change, pronoun use)
Mental Status Exam:
Briefly describe the patient’s mood, affect, and thought processes.
Assess for suicidality if indicated.
Assessment:
Summarize the diagnosis:
Confirmation of gender dysphoria diagnosis based on DSM-5 criteria.
Specify the type of gender dysphoria, if applicable (e.g., gender identity disorder in adolescents and adults, gender dysphoria not otherwise specified).
Level of distress associated with gender dysphoria.
Plan:
Outline the treatment plan based on the patient’s goals and preferences:
Individual therapy: Supportive psychotherapy to explore gender identity, address emotional distress, and develop coping mechanisms.
Social transition support: Guidance and support with social transition steps (name change, pronoun use, presentation).
Medical transition considerations: Discuss the option of hormone therapy and potential benefits and risks, referral to a specialist may be needed.
Support groups: Connecting with others who understand gender dysphoria.
Prognosis:
Briefly discuss the prognosis. Gender dysphoria is a treatable condition. With support and appropriate interventions, many people with gender dysphoria experience significant improvement in their well-being and quality of life.
Emphasize the importance of ongoing therapy and support.
Education:
Document any education provided to the patient regarding:
Gender identity and expression
The nature of gender dysphoria and its treatment options
Healthy coping mechanisms for managing dysphoria
Available resources for support (local LGBTQ+ organizations, online resources)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about social transition, hormone therapy, or accessing support.
Use inclusive language that respects the patient’s gender identity.
Document informed consent discussions for any treatment interventions.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a mental health professional specializing in gender dysphoria for diagnosis, treatment recommendations, and prognosis.