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REFERRAL FORM (Northern BC) For assistance in completing this form, please ask your local Sources staff, who would be happy to assist you. Section A: Primary Focus Person of the Referral Primary Focus

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2. Begin by providing your personal information such as your name, date of birth, and contact details.
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5. Answer questions about your mental health and any history of psychiatric treatment or counseling.
6. Describe your experiences with gender dysphoria and how it has affected your daily life and well-being.
7. Disclose any previous experiences with gender-affirming healthcare, such as hormone therapy or surgeries.
8. Include information about your support network, including friends, family, or organizations that have assisted you in your gender identity journey.
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