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Name*
First Last Post-Nominal/Designatory Letters
Professional Title*
What is your gender? (please choose all that apply)*
- Agender
- Cisgender
- Genderqueer
- Man
- Nonbinary
- Transgender
- Two Spirit
- Woman
- Prefer not to disclose
- Not listed
If not listed, please specify*
What pronouns do you use? (please choose all that apply)*
- ey/em
- he/him
- she/her
- sie/hir
- they/them
- xe/xym
- ze/zir
- Prefer not to disclose
- Not listed
If not listed, please specify*
What is your sexual orientation? (please choose all that apply)*
- Asexual
- Bisexual
- Gay
- Lesbian
- Pansexual
- Queer
- Same gender loving
- Straight/heterosexual
- Two Spirit
- Not listed
- Prefer not to disclose
If not listed, please specify*
How do you racially and/or ethnically identify? (please choose all that apply)*
- Asian American, South Asian, or Pacific Islander
- Bi/Multi-Racial
- Black/African descent
- Caribbean
- Latinx
- Middle Eastern/Arab
- Native American/First Nations
- White/European descent
- Not listed
- Prefer not to disclose
If not listed, please specify*
Please provide a services/practice description. (Please include detail about the services you provide, your experience/expertise working with transgender, nonbinary, gender expansive, and gender nonconforming (TNG) people, and any services that you provide specifically for TNG people, in addition to your general practice/service description.)*
Address*
Street Address City State ZIP Code
Get your Longitude Address and Latitude Address. This will help us pinpoint your location on the map.
Latitude*
Longitude*
Business Hours*
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Phone*
Please provider a phone number to be published on your profile for patients to reach you.
We require an email address so that we can reach you with questions about your profile. Would you like your email to be published on your profile for patients to reach you?*
- Yes
- No
Email*
Enter Email Confirm Email
Would you like to be added to a listserv specifically for providers in WI who are working with TNG people to share resources, ask questions, consult with each other, etc.?*
- Yes
- No
Website
Facebook
Business Social Media
Twitter
Business Social Media
YouTube Channel
Business Social Media
Tumblr
Business Social Media
LinkedIn
Upload Photo*
Accepted file types: jpg, png, Max. file size: 24 MB.
Are you currently accepting new patients?*
- Yes
- No
- Unsure
Do you have a waitlist for new patients?*
- Yes
- No
Specify length in months; if less than 1, write 0*
Have you attended any trainings provided by the Wisconsin Transgender Health Coalition?*
- Yes
- No
- Unsure
Please list all WTHC you've attended*
Click the + icon to the right to add additional trainings
Training Location Date of Training
What type of provider are you? (please select all that apply*
- Surgeon
- Primary Care medical provider
- Specialty medical provider
- Mental health provider
- Sexual health provider (including HIV and other STI testing)
- Substance use/abuse, addiction, and/or recovery provider
- Needle exchange
- Doula
- Acupuncture/Chinese medicine provider
- Chiropractic provider
- Physical/occupational therapist
- Speech therapist
- Dentist
- Optometrist
- Massage/bodywork provider
- Electrolysis/Laser hair removal provider
- Other
If other, please specify*
Approximately how many patients/clients do you see in a year/what is the approximate size of your practice?*
What percentage of the patients you currently work with are transgender, nonbinary, gender expansive, and/or gender nonconforming (TNG)?*
What percentage of the patients you have worked with in the last 5 years are TNG?*
How long have you been intentionally working with TNG people in your practice? (Specify in years; if less than 1, write 0)*
Do you have an office where you provide services?*
- Yes
- No
Which of the following best describes your office location (please select all that apply)*
- Stand-alone office (practice is the only one within the building)
- A building that contains other businesses and/or providers you are not affiliated with
- A clinic (containing other providers affiliated with your system/business/etc.)
- A hospital
- Other
- None of the above
If other, please explain*
If none of the above, please explain*
Which of the following are true for patient transportation to/from your office (please select all that apply):*
- Paid parking lot/structure
- Free parking lot/structure
- Paid/Metered street parking
- Free street parking
- Within 1 block of a bus line/other public transit
- More than 3 blocks from a bus line/other public transit
- No bus/other public transit access
- Provides free transportation to/from appointments
- Provides paid transportation to/from appointments
- Provides full reimbursement for parking/transportation costs
- Providers partial reimbursement for parking/transportation costs
- Other (please explain)
- None of the above (please explain)
If other, please explain*
If none of the above, please explain*
Is your office ADA-compliant or more accessible?*
Click here for a for description of ADA compliance
- Yes
- No
- Unsure
Please explain what barriers to access exist*
Are the office bathroom facilities marked as all gender?*
e.g., anyone of any gender can use any bathroom
- Yes, all
- Yes, some
- No
- Other
- Unsure
If yes, some please describe*
If other, please describe*
Do you provide any of these other types of visits/interventions? (please select all that apply)*
- Home visits
- Services at community organizations
- Electronic visits (e.g., E-therapy, Telemedicine, etc.)
- Phone consultation/counseling/etc.
- Other
- None of the above
- Unsure
If other, please describe*
Do your intake forms allow patients to self-identify their gender, provide their pronouns, and give you the correct name to use, regardless of their legal gender/name?*
- Yes, all forms
- Yes, paper forms only
- Yes, electronic forms only
- No
- Other
- Unsure
If other, please describe*
Are both the name in use and pronouns in use of the patient (regardless of their legal name and gender) used in all referrals (for lab testing,, to other agency Departments, to other health providers, etc.) and print-outs (wristbands, orders, lab results, etc.) ?*
- Yes, all
- Yes, some
- No
- Other
- Unsure
If yes, some please describe*
If other, please describe*
Do your forms/records allow patients to easily change their gender, pronouns, and name?*
- Yes, all paper and electronic
- Yes, paper only
- Yes, electronic only
- No
- Other
- Unsure
If other, please describe*
Do your forms/record allow different gender markers on patient records and patient insurance, depending on the individual patient’s needs (e.g., sex marker on insurance is “M” and gender marker on records is “F”)?*
- Yes
- No
- Other
- Unsure
If other, please describe*
Do you have nondiscrimination and anti-harassment policies that include sex, gender identity/expression, and sexual orientation for staff and patients?*
- Yes
- No
- Other
- Unsure
If other, please describe*
Are these policies effectively enforced to protect patients from anti TNG discrimination (by staff) and harassment (by staff and other patients)?*
- Yes
- No
- Other
- Unsure
If other, please describe*
Who in your agency/office has received training to provide inclusive and affirming care and/or customer service for TNG patients?*
- Self
- All medical staff
- Some medical staff
- All management/leadership staff
- Some management/leadership staff
- All office staff
- Some office staff
- Other
- No one has received training
- Unsure
If some medical staff, please describe*
If some management/leadership staff, please describe*
If some office staff, please describe*
If other, please describe*
Do you require patients/clients to show ID to receive your services?*
- Yes
- No
- Unsure
What kind of ID can patients use to access your services? (select the ID(s) you accept and then mark if each one is required and whether or not it must be unexpired)*
- State ID/Driver’s License
- U.S. Passport
- Passport from another country
- Social Security Card
- Birth Certificate
- Municipal ID
- Student ID
- Employee ID
- Military/Veteran ID
- Permanent Resident Card (“Green Card”)
- Visa
- Employment Authorization Document
- Native American Tribal Document
- Other
If other, please describe*
State ID/Driver’s License
- Required
- Unexpired
U.S. Passport
- Required
- Unexpired
Passport from another country
- Required
- Unexpired
Social Security Card
- Required
Birth Certificate
- Required
- Unexpired
Municipal ID
- Required
- Unexpired
Student ID
- Required
- Unexpired
Employee ID
- Required
- Unexpired
Military/Veteran ID
- Required
- Unexpired
Permanent Resident Card (“Green Card”)
- Required
- Unexpired
Visa
- Required
- Unexpired
Employment Authorization Document
- Required
- Unexpired
Native American Tribal Document
- Required
- Unexpired
Other
- Required
- Unexpired
Do at least some patients need to pay or provide insurance information to receive your services?*
- Yes, all services
- Yes, some services
- No, all services are provided for free
- Other
If yes, some services, please describe*
If other, please describe*
What types of insurance do you accept? (please select all that apply)*
- I do not accept insurance
- I do not currently accept insurance, but will in the future
- Private insurance
- Title 19
- BadgerCare Plus
- Wisconsin Medicaid
- Wisconsin Well Woman Program
- Wisconsin Family Planning Only Services (FPOS)
- Medicaid from other states (please specify states)
- Medicare (please specify which Parts A-D)
Specify when you will accept insurance*
Which private insurance provider(s) do you accept?*
What other types of payment plans will you accept/work with patients to create?*
- I only accept insurance.
- Monthly fee for access to services (direct care model)
- Fee-for-service
- Installment payments
- Sliding scale
- Alternative payment (non-cash) options
- Barter or other exchange of services
- Pro bono/donation of services
- Another payment plan
If monthly fee for access to services (direct care model), please describe*
If sliding scale, please describe*
If alternative payment (non-cash) options, please describe*
If barter or other exchange of services, please describe*
If pro bono/donation of services, please describe*
If another payment plan, please describe type & details*
What language(s) do you provider services in personally? (please choose all that apply)*
- American Sign Language
- Chinese – Cantonese
- Chinese – Mandarin
- English
- French
- German
- Hmong/Hmoob
- Japanese
- Russian
- Spanish/Español
- Not listed
- Prefer not to disclose
If other, please describe*
What type(s) of spoken language interpreter services do you have for patients? (select all that apply)*
- In person
- Phone service
- Video service
- Other
- None
If other, please describe*
What type(s) of ASL interpreter services do you have for patients? (select all that apply)*
- In person
- Video service
- Other
- None
If other, please describe*
Do patients pay for interpreter services?*
- Yes
- No
- Other
- Unsure
If other, please explain*
What is the minimum patient/client age at which you provide services? (please specify & explain, if necessary)*
If you work with minors under the age of 18, can you provider health services without disclosing they are TNG to their parent(s)/guardian(s)?*
- Yes, always
- Yes, in some circumstances
- No
- Other
- Unsure
If yes, in some circumstances, please describe*
If other, please describe*
What is/are your areas of specialty?*
What kinds of transition-related/Gender Confirmation surgeries do you perform? (select all that apply*
- Facial Feminization
- Facial Masculinization
- Chondrolaryngoplasty/Thyroid Cartilage Reduction/Tracheal Shave
- Voice Feminization
- Breast Augmentation
- Breast Reduction
- Mastectomy & Chest Masculinization
- Body Feminization
- Body Masculinization
- Orchiectomy
- Vaginoplasty
- Hysterectomy
- Salpingo-oophorectomy
- Metoidioplasty w/o urethral lengthening
- Metoidioplasty w/ urethral lengthening
- Vaginectomy
- Scrotoplasty
- Phalloplasty
- Other procedures not listed above
If other, please specify*
What model do you follow regarding providing GCS procedures for patients?*
- Informed consent
- WPATH 7 Standards of Care
- Previous WPATH Standards of Care
- Other
- Unsure
- None
If other, please specify*
What do you require from patients prior to performing Gender Confirmation/transition-related surgeries? (select all that apply)*
- Full payment
- Partial Payment
- In-person surgical consultation (no remote consult available)
- In-person or remote surgical consultation
- Mental health assessment
- Letter from therapist/mental health provider
- Letter from psychiatrist
- Letter from medical health provider
- Other
- None of the above
If partial payment specify %*
If other, please specify*
What types of transition-related letters will you write for patients?*
- Gender marker change
- Name change
- Gender Confirmation surgery
- “Carry” letters (e.g., identify that they are transitioning, correct name and gender, etc.)
- Other
- None of the above
If other, please specify*
Do you charge patients for these letters?*
- Yes
- No
- Other
- Unsure
If other, please specify*
Cost per letter*
Do you have any other requirements for patients to receive these letters?
What model do you follow regarding providing transition-related/gender care for patients?*
- Informed consent
- WPATH 7 Standards of Care
- Previous WPATH Standards of Care
- Other
- Unsure
- None
If other, please specify*
What kinds of transition-related hormone therapy care do you provide?*
- Initiate hormone therapy
- Continue/maintain hormone therapy from previous prescription
- Continue/maintain hormone therapy from previous non-prescription use (DIY, “street,” etc.)
- Hormone-related monitoring/blood testing (CBC, liver/kidney function, lipid panel, etc.)
- Initiate puberty blockers/GnRH agonists (lupron, etc.)
- Continue/maintain puberty blockers/GnRH agonists from previous prescription
- Onsite injection required (patient must return for each dose)
- Onsite injection offered as an option for patients (patient can return for each dose)
- Safe intramuscular (IM) injection training for patients
- Safe subcutaneous injection training for patients
- Needle/syringe exchange
- Other
- None of the above
If other, please specify*
Prior to initiating pubertal blockers (GnRH agonists) for minor patients, which of these do you require? (select all that apply)*
- Mental health assessment
- Letter from therapist/mental health provider
- Letter from psychiatrist
- Consent from at least one legal parent/guardian
- Consent from both legal parents/guardians (if have >1 legal parent/guardian)
- Initial appointment for patient education/consent (must return for another appointment to start pubertal blockers)
- Other
- None of the Above
If other, please specify*
Prior to initiating hormones for minor patients, which of these do you require? (select all that apply)*
- Minimun Age
- Mental health assessment
- Letter from therapist/mental health provider
- Letter from psychiatrist
- Consent from at least one legal parent/guardian
- Consent from both legal parents/guardians (if have >1 legal parent/guardian)
- Initial appointment for patient education/consent
- Other
- None of the Above
Please specify minimum age*
If other, please specify*
What other types of transition-related medical care do you provide onsite?*
- Surgical consultation
- Surgery
- Mental health screening
- Ongoing therapy/counseling
- System navigation
- Other
- None of the above
If other, please specify*
What other services do you have onsite for patients? (please select all that apply)*
- Laboratory
- Phlebotomy
- X-Ray
- MRI/CT
- Ultrasound
- Pharmacy
- Other diagnostic services/equipment
- Other specialty care
If other diagnostic services/equipment, please specify*
If other specialty care, please specify*
What percentage of your patients are you currently providing transition-related hormone or puberty blocker monitoring for?*
Do you require any of the following for you to write social transition letters (name change, gender change, carry letters)? (please select all that apply)*
- Must complete “real life experience”
- Must be engaged in care with you beyond initial appointment
- Payment
- Other
- None of the Above
If must complete “real life experience", please specify length in months*
If must be engaged in care with you beyond initial appointment, please specify length in months*
If payment, please specify amount*
If other, please specify*
Do you require any of the following for you to write hormone letters? (please select all that apply)*
- Must complete “real life experience”
- Must be engaged in care with you beyond initial appointment
- Payment
- Other
- None of the Above
If must complete “real life experience", please specify length in months*
If must be engaged in care with you beyond initial appointment, please specify length in months*
If payment, please specify amount*
If other, please specify*
Do you require any of the following for you to write Gender Confirmation Surgery letters? (please select all that apply)*
- Must complete “real life experience”
- Must be engaged in care with you beyond initial appointment
- Payment
- Other
- None of the Above
If must complete “real life experience", please specify length in months*
If must be engaged in care with you beyond initial appointment, please specify length in months*
If payment, please specify amount*
If other, please specify*
Which of the following types of services do you provide for patients? (please select all that apply)*
- Individual Therapy
- Family Therapy
- Couples Therapy
- Art Therapy
- Group Therapy
- Peer-facilitated support groups
- Other
If other, please specify*
What model do you follow regarding providing transition-related care for patients?*
- Informed consent
- WPATH 7 Standards of Care
- Previous WPATH Standards of Care
- Other
- Unsure
- None
If other, please specify*
Have you received formal training on the DSM-V and the changes in diagnosis for TNG children and adults?*
- Yes
- No
- Other
- Unsure
If other, please specify*
Do you provide gender segregated groups, counseling, or other services (e.g., “men’s services” and/or “women’s services”)?*
- Yes, all
- Yes, some
- No
- Other
- Unsure
If other, please specify*
How are TNG men, TNG women, nonbinary/GQ/GNC folks able to access services?
- By sex assigned at birth
- By current legal sex
- By gender identity
- By self-selection for best fit
- Other
- Unsure
- They are not able to access these services
If other, please specify*
What other TNG specific services do you provide? (please select all that apply)*
- Education about safer dosage for DIY/“street” hormone use
- Support/services for sex workers who are TNG
- Education/support groups
- Peer-to-peer risk reduction education
- Specific testing/clinic hours for TNG patients
- Other
- None of the above
If other, please specify*
Do you provide needles/syringes that are appropriate for patients to use for:*
- Drawing hormones from vial (ex: 18 or 20 gauge, 1-1½ ” long)
- Subcutaneous injection of hormones (ex: 25, 26, or 27 gauge, ½-⅝” long)
- Intramuscular injection of hormones (ex: 23 or 22 gauge, 1-2” long)
Are you able to provide new needles and syringes without the client bringing used ones?*
- Yes
- No
- Other
- Unsure
If other, please specify*
What kinds of other education/services do you provide onsite for clients?*
- Safe IM injection training
- Safe subcutaneous injection training
- Safe IV injection training
- Injection risk reduction education
- Naloxone/Narcan
- Sexual risk reduction education
- Barriers for safer sex
- Sex work risk reduction education
- Other
- None of the above
If other, please specify*
What services do you provide for patients? (please select all that apply)*
- Individual counseling
- Group counseling
- Co-occurring disorder treatment
- Intensive outpatient
- Inpatient treatment
- Case/care management
- Peer support
- Naloxone/Narcan
- Medication onsite
- Medication prescription
- Detoxification
- Other
- None of the above
If medication onsite, please specify*
If medication prescription, please specify*
If detoxification, please specify type(s)*
If other, please specify*
Is your treatment based on the 12-step model?*
- Yes
- No
- Other
- Unsure
If other, please specify*
Is attendance at 12-step meetings required for clients to access your services?*
- Yes
- No
- Other
- Unsure
If other, please specify*
Do you provide any TNG specific services?*
- Yes
- No
- Other
- Unsure
If yes, what?*
If other, please specify*
What level of dress/undress is required of clients/patients who are accessing services from you? (select all that apply)*
- No level of undress required.
- Patients can undress or remained dressed to their level of comfort.
- Area(s) that I am working on must be uncovered.
- Patients must undress to their underwear.
- Patients can keep any prostheses/braces related to gender/transition and/or medical conditions/disabilities on during the session.
- Nudity is required.
- Other
If other, please specify*
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