Financial Assistance Intake

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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!
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To start, what province do you live in?* This field is required.
Ontario
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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
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Postal / Zip Code
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Country
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Email* This field is required.Please enter your email address. Note that by entering your email you are consenting to email communication from Foria Clinic.
example@example.com
Confirm Email
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Please enter your legal name* This field is required.
First Name
Middle Name
Last Name
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Please enter your name as you would like to be addressed* This field is required.
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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
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Current Date
Date
Year
Month
Day
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Age
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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
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What is your gender?* This field is required.
Cis-woman
Cis-man
Transwoman
Transman
Non-binary
Genderqueer
Prefer not to say
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Which pronouns do you use?* This field is required.
They/them
She/her
He/him
Ze/zir
Other
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Do you have a primary care provider?* This field is required.
Yes
No
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Do you live within 50km a city with 250,000 or more people?* This field is required.
Yes
No
I'm not sure
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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
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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)
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Do you have any questions we can help with?
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Ok
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