Transgender Speech Therapy Form

Today's Date

Referral Source:

1. Who referred you to this clinic?

2. What do you hope to gain from my services?

3. Why have you chosen to seek these services at this specific point in time?

General Information:

1. Name

2. Legal Name (if Different)

3. Date of Birth

4. Sex Assigned at Birth:

5. Gender Identity

6. Which pronoun would you like to be addressed by?

Address

7. Street Address

8. Phone (home, cell):

• Where would you like to be contacted?

• What name would you like to be addressed by at this number?

9. Email Address:

• What name would you like to be addressed by at this email?

10. Domestic Status:

11. Level of Education:

Transition Information:

1. How long have you been in transition?

2. When did you start presenting in public as female?

3. What percentage of time do you live as female each week? How long have you been at this percentage?

4. What percentage of time do you plan to implement transitional techniques associated with voice modification each week?

5. Are you taking any estrogen or other hormones? If so, which medications, for how long, and at what dosage?

6. Are you currently seeing a counselor or psychologist?

7. Are you receiving electrolysis?

8. Have you had or do you plan to have cosmetic surgery?

9. Have you had or do you plan to have facial or vocal surgery that may affect your vocal mechanism?

10. t)escribe in your own words what you hope to gain from voice modification services.

11. What other therapy, if any, have you had for voice and communication? Was it helpful? Please describe.

12. What other resources, if any, have you used to assist with your voice or communication (e.g., magazines, websites, videos, discussion groups)? Was it helpful? Please describe.

Medical Information:

2. Please list all medications you are currently taking:

3. Significant illnesses and injuries:

4. Surgical history:

5. Have you had any trauma to the head, neck, or chest regions? If yes, please describe.

6. Have you been treated by a speech pathologist or other voice professional in the past?

7. Water intake (glasses per day):

8. Caffeine intake (glasses epr day):

9. Alcohol intake (glasses per week):

10. Smoking History:

Non-smoker

Current smoker

Former smoker

Vaper

How much and how often? What type?

11. Personal history of any recreational drug use:

12. Do you ever lose your voice? If so, how often and for how long?

13. Do you have any difficulties with your voice? If so, please describe.

14. Vocal Activities

Describe all that apply

Talking - Phone

Talking - Conversational

Talking - Public Speaking/Lecturing

Talking - Noisy Setting

Yelling or Shouting

Whispering

Coughing/Throat Clearing

Singing

Other

Employment Information:

Occupation /Employer:

2. Do you present as female at work?

3. What percentage of your work day is spent speaking? What percentage of your recreational time is spent speaking?

4. Does your job involve public speaking or lecturing? If so, what length of time do you speaking and is amplification available?

5. Will you need to leam how to communicate differently at work?

6. Have you spoken to your boss about your transition?

7. How is your transition being supported at work?

Community Integration and Support System:

1. In what social situations do you present as female?

2. Do you present as female to your immediate family?

3. Do you present as female with extended family or friends?

4. How supportive are friends and family of your transition?

5. What support groups, if any, do you attend?

Is there anything I haven't asked that you think I should know?

Transgender Communication and Voice Case History Form