Gender Health Appointment Request

The UCLA Gender Health Program’s Care Coordination Team’s goal is to help you navigate your gender-affirming care at UCLA Health. The first step in working with the Care Coordination Team is a 20–40-minute intake over the phone.

During the phone intake appointment, our team will ask a variety of questions that will allow us to streamline your care through our health system and help us link you to any additional information or community-based resources you might need.

Intake appointments are typically available on Monday through Friday from 9 am – 4 pm PST, although we may be able to accommodate alternative schedules by request.

We are currently receiving an especially high number of appointment requests, and our current response time is about 5 business days. Thank you for your patience as we work to offer personalized support to each request.

Patient’s Legal First Name *

Patient’s Legal Last Name *

Patient’s Used or Preferred Name

Patient’s Pronouns

Are you a parent or guardian completing this request on behalf of the patient?

Parent or guardian’s name, if applicable

Parent or guardian’s pronouns, if applicable

Health Insurance Type: *

PPO/EPO

HMO

Medicare

MediCal

Out of State Medicaid

No Health Insurance

Other (explain in notes)

Health Insurance Notes:

Patient's Date of Birth *

Have you been a patient at UCLA Health before? *

I prefer to be contacted by *

Please enter a brief description of the reason for your visit *

I agree to receive communications from UCLA Health

Gender Health Appointment Request

Phone Intake Visit