First Name
Last Name
If no, what is the injured party’s name?
What is your relationship to the injured party?
Please fill out the remainder of this form regarding the injured party.
Date of Birth
Phone
Email
Your StoryEvery individual treated with gender-affirming care has a unique story. Please
share yours, beginning with your decision to pursue gender-related treatment.
The Specifics We understand that because each story is unique and so it may be difficult to fill out each of the
questions below. Please make every effort to answer each question, or explain why you are unable to
answer, in order to best assist our legal team with their analysis of your possible claim.
If yes, at what age?
If yes, at what age?
If yes, when and what steps have you taken?
Your Treatment
What state were you primarily treated in?
If yes, when?
Who diagnosed you with gender dysphoria?
Please enter the clinician’s
name, their facility/location, and their specialty, if any.
Were you referred to another doctor for treatment?
Please enter the clinician’s name, their facility/location, and their
specialty, if any.
What did your doctors discuss with you for possible treatment options? Please check any boxes that apply
Surgical interventions
Other (Describe)
If yes, when did you take them?
From
To
By whom?
Please enter the clinician’s name, their facility/location, and
their specialty, if any.
If yes, when did you take them?
From
To
By whom?
Please enter the clinician’s name, their facility/location, and
their specialty, if any.
If yes, please describe
By whom?
Please enter the clinician’s name, their facility/location, and
their specialty, if any.
If yes, when?
If yes, please describe
By whom?
Please enter the clinician’s name, their facility/location, and
their specialty, if any.
Other than those already discussed, were you prescribed any other treatments?
If yes, please enter the clinician’s name, their facility/location, and
their specialty, if any.
What do you believe your doctors did, or did not do, to cause injury to you?
What injuries have you sustained?
Please describe all physical, emotional, mental effects.
What date did your doctors take those actions that caused you injury?
Did you receive follow up treatment?
Please include dates, locations, and
treatments provided.
Is there anything else you think we should know?
To evaluate your potential legal claim, please include any other information you believe would assist us.
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