Gender Group Interest Form + Registration
with Julia Simone Fogelson, LCSW, CST 
julia@juliapsychotherapy.com
You can apply anytime for the next group or future groups.

The next cycle will start when I have enough interested participants. I will contact you when a future group starts.

Time TBD, duration 60-90 minutes depending on number of members

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Email *
Name *
Pronouns *
Phone number *
What city do you reside in? Members must be located in California due to my California state therapy licensing restrictions. *
How did you find this group? *

What days/times are you available for a weekly group for 10 weeks?

*The group cycles for 10-sessions and then restarts. New members can apply to join at every new cycle beginning. A closed-group like this helps keep our group connection and build trust and safety within the group.*

*
Have you been in individual therapy before or currently? *
Have you been in a therapy support group before or currently? *
What topics would you like to see the group cover? *
Is there anything you would like me to know about you? *
This group is offered on a sliding-scale model of $0-$100 per week with $100 considered the true cost. Considering your resources, what can you sustain to pay each week throughout the 10-week duration? 

For more information on the sliding-scale framework, I recommend: wortsandcunning.com/blog/sliding-scale, of which I have pulled the following guidelines from:

Lower cost: I am struggling to pay for my basic needs, such as health care, housing, food etc.

Middle cost: I can pay for my basic needs, but am not able to build savings or conquer debt.

Highest cost (true cost): I have financial security and economic privilege. I am able to pay for "wants" and spend little time worried about securing necessities in my life.

Your acceptance into the group does not depend on your ability to pay. I firmly believe in sliding scale and access to care regardless of financial privilege. Please note that if you are able to pay on the higher end of the sliding scale, it will help me continue to offer care for those who cannot afford to.

You will be charged weekly unless you have cleared the days you are unable to attend before the group starts (see previous box) or cancel before 48-hours. 
*
Thank you so much! I will be in contact with you soon. 
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