Gender-affirming care
Letters of support for gender-affirming care.
Respectful, unhurried assessments and letters of support for adults seeking gender-affirming surgery, from Earl Johns, a board-certified psychiatric nurse practitioner and LGBTQ+ provider. In person in San Francisco or by telehealth across California.
How it works
Your walk to wellness.
01
Reach out
Every journey begins with a single step. Book a free 15-minute phone call where we’ll explore your goals.
02
Getting to know you
We take time to truly understand you: your story, your strengths, and the challenges you’re facing.
03
Grow together
Through ongoing visits, typically every 2 to 8 weeks, we work toward goals tailored to your needs.
04
Find peace and wellness
Feel grounded, balanced, and at peace, with a plan that supports your wellness.
What to expect
Care that fits your life.
Here’s what working together looks like, from your first visit on.
Your first visit
45 to 90 minutes. We listen to your story, your challenges, and your goals, then build an individualized plan that may include therapy, lifestyle strategies, nutrition, and medication when appropriate.
Follow-up visits
25 min
Focused medication visits, best if you already see a therapist
45 min
Medication management plus brief therapy (DBT, CBT, ACT)
60 min
Deeper therapy and mind-body work
Visits range from weekly to every 2 to 3 months, depending on your goals.
Between visits
Questions don’t always wait for your next session. Reach us by phone or email and we’ll respond within 3 business days.
Visit location: Secure HIPAA-compliant Zoom, or in person in San Francisco by request. You’ll need to be in California at the time of each visit. ADHD evaluations, including QbCheck computerized testing, are also available.
Who we see
Children and teens (ages 6 to 17)
Adults (ages 18 to 64; not currently accepting Medicare)
LGBTQIA+ people, including gay, lesbian, bisexual, trans, nonbinary and questioning folks
Neurodivergent people, including ADHD and autism
Trauma survivors and people working through grief or big life transitions
Professionals facing burnout and stress
Allies and families of LGBTQIA+ and neurodivergent people
Insurance
We’re in network with these plans:
Aetna
Anthem Blue Cross California
Carelon Behavioral Health
Cigna
Oxford / Optum
Quest Behavioral Health
United Healthcare / Optum
Paying out of network? We provide superbills for PPO reimbursement. Copays vary by plan, so check your benefits with your insurer.
Not sure where to start?
Book a free 15-minute phone consult. We’ll talk through what’s going on and help you decide on next steps, with no pressure.
Book a free consult
How we help
An affirming process, not gatekeeping.
You know who you are. Our role is to complete a respectful assessment, document what your surgeon or insurance plan needs, and support your mental health along the way.
Book a free consult
1
Letters of support for gender-affirming surgeries, including top and bottom surgery, for adults 18 and older.
2
An assessment that follows current WPATH Standards of Care, written to meet what surgeons and insurance plans typically ask for.
3
Most letters take about one visit. Some plans ask for two letters from different providers, and we can help you plan for that.
4
Ongoing support for anxiety, depression, dysphoria and stress before and after surgery, if you want it.
5
Coordination with your surgeon, hormone provider or therapist, with your permission.
6
Letter time is included for self-pay visits. For insurance clients, it’s billed separately, as listed on our Fees & policies page.
7
In person near Union Square or by telehealth anywhere in California.
Gender-affirming care
Common questions about letters.
Anything else, ask us on your free phone consult.
Do I need a letter to start hormones?
How many letters do I need for surgery?
Can a psychiatric nurse practitioner write my letter?
How long does it take?
Will insurance cover the visit?
Do you see people under 18 for letters?
Just like the way waves break.
You’re not broken. You’re not alone.
And this isn’t the end of your story, just a new chapter. Our care is rooted in science, shaped by lived experience, and delivered with humanity.
Book a free consult
Services