Our practice  follows the Informed Consent model and does not require a letter from a therapist or mental health professional for adult patients under most circumstances.  We very much value therapists as part of the process of a gender transition, but a letter is not a requirement. It is important to note though, that if you are pursuing insurance coverage of your surgery, you will need to get at least one letter from a mental health provider if your health insurance provider follows the WPATH Standards of Care for coverage of surgery.