Clone of Healing Under Fascism Registration Form

Summer Dysphoria Support Group Registration

Please enter your details below to register for the 6 week support group on body image and gender diversity in the summertime. You will be reached out to with follow-up details. (Note: address will be used simply to send welcome materials).
Full Name

First NameLast Name
Pronouns
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
What are your goals for this group? What brings you here?
Have you ever experienced any of the following? (select all that apply)
Are you currently working with a therapist, dietitian, or doctor for concerns related to eating or food?"
Can you agree to these group expectations?
How did you hear about us?
Please Specify
Group Pricing
prevnext( X )
Tier I - $90
$15 per group

$90.00 Quantity



Tier II - $180
$30 per group

$180.00 Quantity



Tier III - $300
$50 per group

$300.00 Quantity



Total

$0.00
Would having payments broken into four spaced-out payments throughout the group be better for you?
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

Summer Dysphoria Support Group Registration