TEST TEST Gender Affirming Care - Service Access Form Client's Chosen Name(Required) Last name(Required) Client's Pronouns They/Them She/Her He/Him Other Date of Birth(Required) MM slash DD slash YYYY Suburb Client Lives In(Required) Preferred Contact (email or phone number)(Required) Secondary Contact (email or phone number)(Required) Preferred Contact Time (check all that apply)(Required) Weekday morning Weekday afternoons Is an interpreter needed?(Required) Yes No If yes, what language interpreter do you need? Are there other accessibility needs?(Required) Yes No If yes, please give details of accessibility requirements. Are you requesting services for yourself?(Required) Yes No If you are requesting services for someone else, what is your relationship to them? Parent/Guardian Family Member (family of origin or family of choice) Friend Carer Health or Support Worker Other If you are requesting services for someone else, please include your details belowDo you already have a GP who you are open with about your gender?(Required) Yes No Prefer not to say If yes, please include their details below.What services would you like to access (check all that apply)?(Required) General health services at our clinics Gender affirming health services at our clinics Testosterone administration you already have prescription for (visit www.yourch.org.au/gaht-form for steps) Peer Navigation providing you with information about services and possibilities in trans care in Victoria with the support of a lived experience worker Endocrinology with Austin Hospital Psychiatry with Austin Hospital Training and resources for my referring doctor Please include any notes you would like to add here:EmailThis field is for validation purposes and should be left unchanged.
