Gender Marker and Name Change Questionnaire
What is yourlegal name?
What do you want your legal name to be?
What is your legal gender? M / FWhat do you want your gender marker to be? M / F
What is your race? What is your date of birth?_____
In what city, county, & state were you born?City:County?State:
What is your SSN?
What is the state and # of all driver’s licenses and/or IDs issued to you in the last 10 years?
#: State: DL/ID (circle one)
#: State: DL/ID (circle one)
#: State: DL/ID (circle one)
#: State: DL/ID (circle one)
When did you start receiving treatment for your transition?______
Do you currently or have you ever received treatment for your gender transition from a licensed physician? Yes / No
If yes:1) Physician’s name: Type of medical professional:
Office name: Office Address:
How long have you been seeing this doctor?
2) Physician’s name: Type of medical professional:
Office name: Office Address:
How long have you been seeing this doctor?
3) Physician’s name: Type of medical professional:
Office name: Office Address:
How long have you been seeing this doctor?
Do you currently or have you ever received treatment for your gender transition from a licensed therapist? Yes / No
If yes:1)Therapist’s name: Qualification (MD, LMSW, etc.):
Office name: Office Address:
How long have you been seeing this therapist?
2) Therapist’s name: Qualification (MD, LMSW, etc.):
Office name: Office Address:
How long have you been seeing this therapist?
Have you ever been arrested? Yes / NoIf yes, what in what counties? ______
Have you ever been charged with a crime above a Class C misdemeanor? Yes / No
If yes:What is your SID #?What is your FBI #?
1)Offense: Cause #: County & State:
Date of final disposition: Outcome:
2)Offense: Cause #: County & State:
Date of final disposition: Outcome:
3)Offense: Cause #: County & State:
Date of final disposition: Outcome:
4)Offense: Cause #: County & State:
Date of final disposition: Outcome:
5)Offense: Cause #: County & State:
Date of final disposition: Outcome:
*********************************************************************************************************************
Your Name:
Your Bar No.: Date of Interview:
Please describe what legal advice you provided:
Additional impressions you had or other information you think HVL should know:
YOUR RECOMMENDATION:
[ ] CONTINUED REPRESENTATION NEEDED**
[ ] NO FURTHER ACTION NEEDED – provided Advice & Counsel only
[ ] PROVIDED LIMITED ACTION by (e.g., made phone call or completed pro se answer)
[ ] I would like to take this case.
Gender Marker and Name Change Questionnaire, Page 1 of 2