Waitlist-PWYC

To maintain our equitable values in providing Therapy Services to those with financial accessibility needs please note the following:

Pay What You Can appointment slots are available for a six-month period with the possibility of an extension depending on the number of folks on the waitlist.

PWYC can only be accessed by clients with an annual individual income of ≤ $25,000, pending availability

A minimum of $65 per 50-minute individual session, and $170 per 70-minute group (Couples+/Parent-Child) session is requested.

Individual Annual Income

Please provide your individual gross annual income to your best knowledge.

Requested Session Fee

A minimum of $65 per 50-minute individual session, and $170 per 70-minute group (Couples+/Parent-Child) session is requested

Name

First Name

Last Name

Chosen Name

What name would you like me to refer to you by?

Pronouns

I go by "he, him" pronouns. How would you like me to refer to you? If/when at any time you felt more comfortable with different or more pronouns than what you shared here, please let me know so I can continue to refer to you with your chosen ones.

Phone

Country

(###)

###

####

Privacy and Security

I understand that communications via email over the internet are not secure. Although unlikely, I understand that there is a possibility that an unintended party could intercept and read the contents of an email. I also give Just Healing Psychotherapy permission to leave a message at the phone number and email address provided.