Your Body is the World Registration

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Legal First and Last Name *

Name you wish me to call you *

What are your pronouns? *

Please provide an email you check regularly *

How did you hear about this group? *

Facebook

Instagram

A previous group of yours

An email from you

Therapist

Website

Psychology Today

Other:

What drew you to this group?/Why are you interested in joining? *

Have you been involved in group work before? If yes what was your experience like? *

Please check the following statements to indicate your understanding and agreement *

I understand I am responsible for payment of sessions regardless of attendance (fee information below)

I am available Monday nights at 6pm PST for all sessions of this group

I am generally willing to be on camera during virtual meetings but understand I can be off camera if access needs prevent me from doing so

Required

Here is a little information about my values and approach to the idea of wellness. I do a lot of work around health at every size approaches to body image healing which means I try to make all of my groups explicitly fat/body positive and anti-diet culture. My caseload is made up of mostly queer and neurodivergent folks so I also try to create spaces that honor intersectionality and access needs. Please indicate below your comfort level with participating in a space that is grounded in social justice. *

I understand and am comfortable with these values and doing work that is grounded in social justice

I have questions or concerns about this

Other:

The fee for this group is based on a sliding scale system which is $60-$80 per session (you choose what you pay) Those that need to pay less can pay less (no proof of income required) And those that can pay more are asked to do so to subsidize those that need to pay less. You know your financial situation best and I trust you to make decisions about your own resources. Payment is taken on a weekly basis by default.Please indicate below where on the scale you would like to pay per session *

Once you have completed this form you will receive an invitation via email to set up your account in my EHR system, Simple Practice where you will sign consent documents, fill out your card info, and sign your fee agreement. Once those documents are signed you are officially registered for the group. Note: groups can take anywhere from 4-12 weeks to fill. The holiday season can add additional waiting time/complexity to scheduling. *

I understand and will check my email regularly so I can complete the rest of the registration process

I under stand that I may have to wait multiple months for the start of this group

Do you have any questions for me or access needs you would like me to address?

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