Appendix: Sample Language for Healthcare Certification

Healthcare Certification^[1]

[Date]

To Whom It May Concern:

I am a licensed [counselor, nurse practitioner, physician, physician assistant, psychologist, social worker, or therapist], and I have treated or evaluated [patient’s name] in relation to [patient’s name]’s gender identity. In my professional opinion, [patient’s name]’s gender identity is consistent with a designation of [male or female].

Patient’s Information:
Full Name:
Date of Birth:

Healthcare Professional’s Information:
Full Name:
Organization (if any):
Address:
Phone Number:
License Type: [counselor, nurse practitioner, physician, physician assistant, psychologist, social worker, or therapist]
License Number:
Issuing State, Country, or other Jurisdiction of License:

Sincerely,

[Healthcare Professional’s Signature]

[Healthcare Professional’s Printed Name]