Financial Assistance Intake

1

Financial Assistance

We recognize that the cost of Foria's services are prohibitive for many who need gender-affirming care. We are currently working on establishing a financial assistance program with the goal of providing care to as many people as possible.

If you are interested in applying for financial assistance when the program is ready, please fill out this form and we will be in touch with details as soon as we can.

Thank you!
2
To start, what province do you live in?* This field is required.
Ontario
Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
3
Where are you currently located?* This field is required.Please note that you must be located in Ontario at the time of your consult in order to receive care from Foria Clinic
Street Address
Street Address Line 2
City / Town
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.Please enter your email address. Note that by entering your email you are consenting to receive email and marketing communications from Foria Clinic and can withdraw your consent at any time.
example@example.com
Confirm Email
5
Please enter your legal name* This field is required.
First Name
Middle Name
Last Name
6
Please enter your name as you would like to be addressed* This field is required.
7
Date of Birth* This field is required.Foria Clinic is only accepting patients that are 18 and over, but we are working to serve younger patients as soon as we can. If you enter a date of birth that is less than 18, we will be in touch with you when we can serve you!
Date
Year
Month
Day
8
Current Date
Date
Year
Month
Day
9
Age
10
Foria is only accepting patients 18 years of age and older at this time* This field is required.You can still complete this form and we will be in touch when we can serve you!
I understand that I do not meet the age requirements for Foria
11
What is your gender?* This field is required.
Cis-woman
Cis-man
Transwoman
Transman
Non-binary
Genderqueer
Prefer not to say
Other
12
Which pronouns do you use?* This field is required.
They/them
She/her
He/him
Ze/zir
Other
13
Do you have a primary care provider?* This field is required.
Yes
No
14
Do you live within 50km a city with 250,000 or more people?* This field is required.
Yes
No
I'm not sure
15
What services would you be interested in?* This field is required.Select all that apply
Testosterone & Masculinizing Hormone Therapy
Estrogen & Feminizing Hormone Therapy
Surgical Referrals
Letter for Gender Marker Change
Mental Health Concerns
Episodic Primary Care
Lifestyle Medication (ie. PrEP)
Other
16
Which statement best describes your current experience with gender-affirming services?* This field is required.
I was a previous active patient of Connect-Clinic and want to book a follow-up with Foria
I was previously waitlisted at Connect-Clinic and want to book a new service with Foria
I am just starting to look for gender-affirming services and want to book a new service with Foria
I am currently waitlisted elsewhere for gender-affirming services but want to receive care sooner (via an initial consultation or transfer of my care to Foria)
I am currently receiving gender-affirming services elsewhere but am exploring other options (ie transfer in)
17
Do you have any questions we can help with?
Huge
Large
Normal
Small
Ok
Ok
18
Should be Empty: