Transgender History Questionnaire (Created by Dr. Rachael St. Claire and used with her permission) Please note: Due to HIPAA constraints, it is not possible to save this form and complete later. It must be completed in a single session. Step 1 of 6 16% Date Email* Name First Last Also Known As (AKA):Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Work PhoneOk to leave a message or contact via email?:AgeDate of Birth Employment and Occupation Information: What work do you do, by whom are you employed?Problem ListWhen you think about your gender and sexuality, describe what help you are seeking from counselingDescribe any problems you are having functioning in your day to day life.Are you currently having a problem with any of the following?: Depression or Sadness Problems at Work Partner Problem Anxiety or Fears Financial Problems Physical or Emotional Abuse Family Problems Unemployment Have you ever had a problem with the following?: Alcohol Use Drug Use Child Abuse Violence Legal Problem Suicidal Thoughts or Behavior Depression Hearing Voices Have you experienced any of the following in the last month?: Sadness or Emptiness Low Energy Level or Lethargic Poor Attention or Concentration Poor Self-Esteem Irritability Thoughts About Suicide Disturbed Sleep or Insomnia Loss of Appetite Unable to Experience Pleasure Excessive Guilt Feelings Hopelessness Thoughts that Death is Better than Life Gender Identity InformationDescribe how you feel and think about your gender.Explain how you are currently expressing your gender in your everyday life.Describe what problems or conflicts with gender you are experiencing.Describe any difficulty you experience between your gender and biological sex.Do you identify with any specific gender or sexual group? Please explain.Describe any past or present experiences with gender support organizations.Who have you spoken to about your gender identity issues, what do they know, and how have they responded? Medical InformationAre you currently taking medications, hormones, or supplements to induce feminine or masculine changes in your body, for example estrogen or testosterone?*YesNoIf you are taking hormones or supplements, please list name and dosage.Is there a prescribing physician? Please list address and phone number.If you have taken gender medications in the past and stopped, list the medications, when you took them and why you stopped.Describe any surgery to alter gender appearance, the surgeon's name, and when the surgery was performed.If you are currently taking any medications for a medical condition, list the medical condition and medication. Mental Health InformationIf you have seen a psychotherapist in the past, please list their name, when, and the problem at the timeIf you have taken medications for mental health reasons, for example despression or anxiety, list the medications and when taken.If you have ever been in the hospital or emergency room for mental health reasons, list when, where and the reason.Family InformationAre you currently married?YesNoIf yes, please list your spouse's name.If you have children, list their names and ages.Have you previously been married? Yes No List dates of any previous marriages.List parents, brothers, and sisters with their ages.Briefly describe any important impressions about your childhood family life.Briefly describe your current relationships with each of your family members. Military HistoryIf you served in the military, please list which branch.From when to when?Discharged at what rank?Type of Discharge?Did you see combat? Any comments about your experience in the military.Educational BackgroundHighest level of education achieved?Are you currently a student?YesNoReligious BackgroundWere you raised in a religious home?YesNoWhat religious tradition was that?Was religion a help or a hindrance to your emerging sense of self?Do you have a religious affiliation today?YesNoDenomination?Do you have a spiritual practice, see yourself as a spiritual person?YesNoIs your spirituality or religious life something you want to talk about in therapy? Life StoryPlease write a personal story about how your experience and understanding of your gender identity and sexuality has changed over the course of your life. How did you first discover that your biological sex did not fully express your inner experience of your of your gender? Was this difficult? What have you learned about yourself and how have you grown? How have you tried to resolve your gender identity issues throughout your life? What is the vision for your future as a gendered person?PhoneThis field is for validation purposes and should be left unchanged.