Circuit Court Forms

FORM 37T

CERTIFICATE OF ENDOCRINOLOGIST OR PSYCHIATRIST (SECTION 12(4) OF THE GENDER RECOGNITION ACT 2015) — APPLICATION FOR A GENDER RECOGNITION CERTIFICATE

I ........ of ..........., *[endocrinologist] *[psychiatrist] hereby certify as follows:

1. I have no connection to ............, who ordinarily resides at .......... (“the child”);

2. I have met the child for the purposes of this certificate.

3. I have read the certificate of ........., medical practitioner, and I concur in my medical opinion with that certificate.

Signed ............

Dated .............

*delete where appropriate