CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Identity Supportive Intake Guidelines and Culturally Responsive Assessments with LGBTQIA2-S Clients

Psych - 09
 
Category: Psychotherapy
Published Date: April 2026
 
 
  1. PARAMETER GOAL
    1. To provide workforce guidance on identity supportive intake protocols at the Los Angeles County Department of Mental Health.
  2. TERMINOLOGY
    1. Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Two-Spirit (LGBTQIA2-S+)-The plus is added to be inclusive of other identities/labels that may not be included in the acronym.
    2. Sexual Orientation / Gender Identity (SOGI): Reference to identity only.
    3. Sexual Orientation / Gender Identity / Gender Expression (SOGIE): Reference to identity, perceived identity, and / or gender expression.
    4. Suggested phrases for use with clients are in bold. 
  3. BEFORE CLIENT ENCOUNTER GUIDANCE
    1. Self-Awareness and Reflection
      1. Be aware of how you present yourself and be mindful of creating a safe and affirming environment. 
      2. Be aware that some folks have already experienced prejudice, microaggressions, and trauma in institutions when seeking help and other services.
      3. Best practice is to apologize when you make a mistake – practice this skill if needed. 
      4. Be aware of your biases and prejudices. Do seek consultation and supervision if these biases and prejudices impact your ability to give quality care to LGBTQIA2S+ clients.
    IV.  INTRODUCTION
  1. Do's
    1. Include pronouns   - “My name is ______.  My pronouns are ______". 
    2. Ask client how they would like to be addressed.  “How would you like me to address you?” “What pronouns do you use?”
    3. Apologize when you a make a mistake - Keep it simple and straightforward: “I apologize, I meant to say (correct pronouns)” – and then move on with the conversation
    4. When indicated, acknowledge how negative interactions regarding their sexual orientation and/or gender identity (SOGI) could be traumatizing. 
    5. Remind the client that they can choose to wait to disclose certain information/details if they prefer until they see their mental health provider. 
    6. Be aware that the intake may differ when it is specifically to access identity-supportive mental health resources/services versus a typical intake to initiate mental health support services. 
[Rationale: It can be intimidating coming into an agency, not knowing how they will be treated, especially if there are no visible signs that the agency or staff are affirming. If they are seeking a mental health evaluation for identity affirming (identity supportive) medical treatment, this appointment can already feel like a burden/barrier.]
  1. Avoid
    1. Avoid challenging the pronouns one chooses to use.
    2. Do not deadname [deadname: someone’s given name (e.g., the name on their ID), when that person goes by a chosen name that is different from their given name] 
    3. Do not make assumptions 
    4. Do not over-apologize if you make a mistake (Rationale: It burdens the client in feeling obligated to help you manage your feelings) 
V.  MANDATED REPORTING AND MATTERS OF CONFIDENTIALITY
  1. Clarify what is shared with their consent and what may need to be reported and why (e.g. mandated reporting)
  2. Youth – confidentiality between client and therapist
    1. To develop rapport and trust, clarify with caregiver and client that therapist will not disclose what the youth says in session, except in cases that the clinician is legally obligated. Provide examples of scenarios (e.g. harm to self or others, abuse [caregiver may not be alerted but other agencies will]).
[Rationale: This is an opportunity to lay the groundwork of trust and a sense of safety if they are still in the process of coming out or do not want certain people to know about their SOGI information.] ​

VI. INTAKE DOMAIN REMINDERS AND CONSIDERATIONS
  1. Presenting problem/symptoms: 
    1. Some LGBTQIA2S+ clients will seek mental health support to challenges associated with their SOGI ​​​
      1. [If client relates their psychiatric distress to their SOGI] Tell me a bit about your understanding of [symptoms or behaviors causing distress] and how they relate to your gender/sexuality?  ​When did this start? How is it affecting your life?  
      2. However, other LGBTQIA2S+ clients’ mental health concerns may have nothing to do with their SOGI
        1. If client identifies as part of being in the LGBTQIA2S+ community but reports that is not the reason why they are seeking services, honor their response and address what they are reporting/needing. You can always monitor during the assessment if you suspect they are minimizing.  
      3. Remember that conversion/ “reparative” therapy (efforts to change a person’s SOGI to cisgender and/or heterosexual) is ineffective, harmful, and is unethical within professional mental health treatment
        1. If a client states that they are seeking mental health services to change their SOGI, we should maintain collaborative and curious stance without agreeing to this goal of treatment 
          1. I can see that you are distressed about your gender/sexuality, and I’m glad you are seeking support. We will work together to identify some steps we can take, so you can feel less pain and move toward a life that feels workable and authentic.  
  2. Suicidal Ideation (SI), Self-Harm, and Risk (higher risk)
    1. Importance of identifying protective factors 
      1. LGBTQIA2S+ youth: identifying a supportive adult helps decrease risk of SI 
      2. Distress associated with internalized stigma, isolation, and concealment are particular risk factors among LGBTQIA2S+ individuals 
  3. Medication 
    1. Do not assume all clients who are transgender are taking hormone therapy 
    2. If your client is transgender, gender diverse, or intersex (TGI), you can ask if they have pursued (or if they are interested in) identity supportive medical treatment at some point during their life 
      1. Have you received any identity supportive treatment in the past? This might include hormone treatment, surgeries, or other procedures that some people pursue for identity supportive care. 
        1. (If the answer is no,) is this something you are interested in? 
  4. Developmental history (children, adolescents, and TAY) 
    1. Remember that gender and sexual identity development are nonlinear and a highly personal process. 
      1. Gender expression and gender identity are different elements of a person’s lived experience 
      2. Avoid framing any aspect of your client’s identity development as a “phase” or something they “might grow out of” 
    2. Gender identity starts developing around age 3-5 
    3. Sexual attraction/orientation awareness develops around the onset of puberty (for some it’s earlier, for some it’s later) 
    4. How has your family responded to your SOGIE (Sexual Orientation, Gender Identity, Gender Expression) as you’ve been learning more about yourself or evolving into the person you want to be? (to a child) 
      1. How has your child evolved in their gender expression or sexual orientation over the years? (to the parent) 
      2. How did you feel when your child came out to you? (to the parent) How has the immediate and extended family responded, how has this impacted your relationship with your child?
    5. What messages have you heard from your family/culture about your gender, sexual orientation or gender expression?   
      1. How have these perceptions/messages impacted your SOGIE (Sexual Orientation, Gender Identity, Gender Expression)? 
    6. Who are safe people in your life that have supported you on this journey? 
      1. Who are you closest to and can share your truth? And who has been the least supportive? 
    7. What are some of the positive or negative impacts that puberty had for you when it comes to your SOGIE (Sexual Orientation, Gender Identity, Gender Expression) ? 
    8. At what age did you come out? What was that experience like? Who did you first tell and how that go?
    9. At what age did you first start dating? Tell me about some of your earlier relationships. 
  5. Substance Use 
    1. Inquire about context and function of substance use; LGBTQIA2S+ clients are at elevated risk for problematic substance use, mostly due to coping with stress associated with discrimination 
      1. Could you share a bit more information with me about the role that drugs and alcohol play in your life? What is your relationship like with alcohol and any other substances that you use? 
  6. Disordered Eating 
    1. Inquire about body image and eating patterns; LGBTQIA2S+ community members have elevated risk of body dissatisfaction and unhealthy eating patterns (e.g., restricting, binging, purging), which may be impacted by internalized stigma, traumatic experiences, and/or lack of interpersonal safety or community connectedness 
  7. Medical history 
    1. Access to care: any barriers, such as discrimination from medical staff? 
    2. Identity supportive treatment 
      1. Does client desire identity supportive treatment? Any barriers to access? 
      2. If client has had any identity supportive treatment (e.g., hormone therapy, surgery), how has this impacted client’s overall wellbeing? 
  8. Psychosocial 
    1. Consider how intersectionality impacts a client in various psychosocial sub-categories.  
      1. One’s ethnicity, age, gender, disability, etc. while being a member of the LGBTQIA2S+ community affects their individual lived experience. 
      2. Stay attuned to possible internalized stigma (e.g., negative beliefs or stereotyping about one’s own identity/community) toward client’s own SOGI and/or other salient identities. 
    2. SOGI awareness and coming out
      1. With youth: ask in general about their crushes rather than identifying a specific gender: “Who have you had crushes on?” versus “Have you liked any boys?” 
        1. Questions will be asked differently to make it age-appropriate: “Who gives you butterflies?”  
      2. When did you first start to realize/understand that you are [insert identity here]? What was that like for you? 
      3. Explore the coming out process 
        1. Are there people in your life who know that you are [insert identity here]? What has it been like to discuss your identity with people in your life?  
    3. Education: LGBTQIA2S+ affirming school/staff 
      1. Assess if school is a safe place for client 
        1. Tell me a bit about your experience with school. Do you experience school as a safe and welcoming place for you to be your full self? 
        2. Are you out/open about being [insert identities here] at school? 
          1. How have teachers and other staff responded to this? 
          2. How have your classmates and peers responded? 
            1. Have there been any reactions by your classmates’ or peers’ parents that have interfered with your friendships or other relationships? 
      2. Assess if there are supportive staff on campus 
        1. Client may not be out at school; it is still important to explore whether there are supportive staff on campus. 
        2. Are there any teachers or other staff that you feel like you could talk to if you needed support? 
      3. Assess if there are any clubs specifically for LGBTQIA2S+ students
      4. For transgender clients, assess what name do they go by in school and if peers and staff honor that name (versus deadnaming and misgendering)  
        1. Which name and pronouns do you use at school? Do adults on campus honor this? Do your classmates and peers honor this?  
          1. (If not,) how have you navigated this? 
          2. Are your parents/caregivers aware of the name and pronouns you use at school? How do you feel about this?
      5. Assess if there are safe spaces for students who are transgender to use the bathroom or change for PE 
      6. Bullying: especially if related to client’s SOGIE from peers and/or staff at school 
        1. If bullying has occurred, what has been done to address this? 
        2. Is the caregiver aware of this? 
        3. If not, does the youth want the caregiver involved? 
      7. If youth is home-schooled…
        1. Assess if it is related to being part of the LGBTQIA2S+ community 
          1. Do you know how your parents/caregivers reached the decision to have you homeschooled? Are there any specific identity-based or cultural reasons for being homeschooled? 
        2. Assess whether client is engaged with other youth in the community (including LGBTQIA2S+ community connections)
[Rationale: Assessing the youth’s experience at school can also determine potential risk and resilience factors. School can be a source of support if staff and student body are LGBTQIA2S+ affirming and provide safe spaces for the youth to be their authentic self. However, if the staff and student body are not supportive, there is a high risk for trauma and an exacerbation of mental health symptoms.] 
  1. Employment/Vocational: LGBTQIA2S+ affirming environment 
    1. Because of barriers to employment due to systemic and interpersonal discrimination, LGBTQIA2S+ clients may be more likely to engage in the underground/street economy (i.e., the exchange of money, food, or goods through transactions that may not be legal); be sure to maintain an open, non-assumptive, and nonjudgmental stance  
      1. Tell me a bit about your finances and income. How do you support yourself? 
        1. Have you ever worked outside of a formal workplace in exchange for money, food, shelter, or other resources? 
          1. Did you feel safe engaging in this work? Within the context of your work, were there people you could go to if you felt unsafe or needed any kind of support? 
    2. Assess if work environment feels safe and affirming for client 
      1. Tell me a bit about your experience at work. Do you experience your workplace as a safe and welcoming place for you to be your full self? 
      2. Are you out/open about being [insert identities here] at work? 
        1. How have your supervisors responded? 
        2. How have your colleagues responded? 
    3. Assess if there are supportive supervisors or colleagues at work 
      1. Client may not be out at work; it is still important to explore whether there are supportive colleagues, peers, and/or supervisors 
    4. Assess for any workplace concerns related to client’s SOGIE, such as harassment by supervisors, colleagues, and/or customers 
[Rationale: Assessing the client’s experience at work can also determine for potential for trauma and an exacerbation of mental health symptoms. LGBTQIA2S+ people are more likely to experience discrimination when seeking employment, resulting in more disparities.] 
  1. Legal 
    1. If client has an incarceration history, assess whether client experienced harassment, discrimination, and/or other trauma related to SOGIE during incarceration 
      1. Many transgender individuals are housed in facilities/units according to sex assigned at birth rather than gender identity, placing them at increased risk for violence, isolation, and self-harm 
      2. Many transgender individuals are restricted from accessing/utilizing identity supportive support and treatment during incarceration 
    2. For clients who are transgender, assess whether they have pursued (or whether they desire) a legal change of name or gender marker
  2. DCFS 
    1. LGBTQIA2S+ youth are overrepresented within the child welfare system; many child welfare-involved LGBTQIA2S+ youth experience rejection, discrimination, and hostility before and during involvement with the child welfare system 
    2. Assess whether client is currently, or has ever been, involved with the child welfare system, including experiences with foster homes or group homes (also known as STRTPs) 
      1. Assess whether client felt safe and affirmed in their home environment
      2. For clients who are transgender, assess whether they had access to any identity supportive care while involved with the child welfare system 
      3. Does client feel supported by Department of Children and Family Services (DCFS) Child Social Worker (CSW)? 
      4. Does CSW know youth is transgender? (this helps us know whether we can use the youth’s correct name and pronouns when communicating with the CSW, without accidentally “outing” them).
      5. Is CSW supportive?  
      6. If CSW is not supportive, assist youth in requesting a CSW from the LGBTQIA2-S+ Champion network. 
      7. If they are dependents of the court, and they are interested in pursuing identity supportive treatment, is their attorney aware and supportive? (this is because the attorney will request approval from the court to change legal name, begin medical treatment, etc.) 
      8. Ask the client if they would like a copy of the letter uploaded to IBHIS. The benefit is that they can always call and request that it be printed out and sent to them again, should they need it in the future (sometimes they misplace it, especially for clients with housing or placement instability). Any DMH clinician could download it from IBHIS and send it to them, should they be unable to get in contact with the person that composed the letter. Always ask them and let them decide.
  3. Dependent Care Issues 
    1. Remember that LGBTQIA2S+ clients, like cisgender and heterosexual clients, have children and start families in many ways
    2. LGBTQIA2S+ clients may experience stigma and discrimination when navigating custody disputes and hearings, which can significantly impact their overall psychological wellbeing 
    3. If client has LGBTQIA2S+ child(ren), assess how client feels and has responded to child’s identity 
      1. What was that like for you when your child told you they were [insert identity here]? How did you respond?
        1. Have your thoughts or behaviors changed from the time your child first told you until now? How so? 
        2. Are you connected with any other parents of LGBTQ+ kids? What has that been like?  
  4. Living Situation (Current and Previous)  
    1. LGBTQIA2S+ individuals experience higher rates of homelessness and housing insecurity 
      1. May encounter challenges with finding safe and affirming temporary/transitional housing (especially for clients who are transgender, who often face discrimination around single-gender housing programs) 
  5. Family History
    1. Is family aware of client’s SOGI? How have family members responded? 
    2. Does client have family members with whom they feel safe and affirmed in their authentic self? 
    3. Many LGBTQIA2S+ individuals have a chosen family, which may be particularly important for clients who have experienced rejection from their family of origin or other caretakers growing up 
      1. Tell me a bit about your family, including anyone you consider to be chosen family. 
    4. Remember the importance of multicultural and intersecting identities (i.e. race/ethnicity, national origin, faith/religious background) 
      1. Tell me a bit about the cultural values and identities that were considered important within your family. Did you have any values or identities that were very different from your family’s? What was that like for you? 
        1. Were there any values in the home/family environment that were experienced as being at odds with client’s SOGIE? 
  6. Relationships
    1. Explore client’s involvement with LGBTQIA2S+ communities; how has community involvement (or lack thereof) impacted client’s life? 
    2. Remember that sexual/romantic behavior is distinct from sexual/romantic orientation; do not assume sexual/romantic orientation solely based on client’s current partnership(s), if any, and vice versa 
      1. Do you have any significant romantic or intimate partners? 
      2. How do you feel/do you feel supported with your romantic and/or sexual relationship(s)?​​​​​​
   I. Mental Status Exam 
1. Do not link perceptual disturbance to client’s SOGI 
 
   J. Strengths 

   K. Case Management/Linkage Needs 
  1.  Learn about LGBTQIA2S+ resources within your Service Area (SA) 
    1. Many LGBTQIA2S+ individuals are aware of which resources/organizations are safe and affirming; be sure to ask your client if there is a particular organization they do (or don’t) want to work with 
    2. Vet community resources prior to referring LGBTQIA2S+ clients  
      1. Does the organization have a nondiscrimination policy that includes sexual orientation and gender identity? 
      2. Does the organization have experience working with LGBTQIA2S+ clients? How do they navigate client concerns/complaints related to inclusion or discrimination? 
    3. If client declines LGBTQIA2S+ resources, validate their right to decline even if you think they would be beneficial 
   L. Additional considerations when conducting an intake with youth  
  1. Meeting with youth alone  
    1. Check in specifically about SOGI; do not assume
      1. Is there anything you wanted to tell me, now that [caregiver] isn’t in the room – anything about other symptoms, substance use, sexuality, or other problems – for example?   
        1. Remind them of confidentiality/mandated reporting.   
      2. How would you like me to address you when [caregiver or another adult] is present versus alone?
    2. Caregiver and youth interaction: observe especially if youth respond in a remarkable way, and reflect on observations   
  1. RESOURCES
    1. Cornerstone Learning Link (DMH employees only): 
    2. Sexual Orientation and Gender Identity (SOGI) Concepts and Terminology 
    3. How to Ask About SOGI 
    4. SOGI - Pronouns and Why They Matter 
    5. National LGBTQIA+ Health Education Center 
    6. Resources for Working in Solidarity with LGBTQ+ People (Wellbeing4LA Online Learning Center)