Therapy Program

If you are a college student needing therapy resources, we first recommend visiting the UTD Student Counseling Center or the counseling center at the college where you attend. If you are seeking additional support, Synergy Wesley Foundation provides free therapy for UT-Dallas and Dallas-area college students as funding allows. To enroll and be connected with a therapist, you can scroll below and fill out our therapy form, and we will be in touch to start the process. If you would like to read about the therapists we work with, you can click on a picture of a therapist below to view their website and read more about them. If you have questions or would like more information, please contact our Therapy Program Coordinator at: Morenike@EmpoweredHealingDallas.com

https://www.mindfulpossibilities.org/team

Student Intake Form for Therapy

If you are needing more immediate resources, we recommend contacting the UTD Student Counseling Center or comparable program at your college. If you are experiencing a life-threatening emergency, please call 911. If you are a UTD student in crisis and need to speak to a mental health professional, call UTD TALK (972-883-8255).

You can fill out the form below to start the process of getting connected with a therapist this Fall, and we will be in touch!

Name

First Name

Last Name

Pronouns

Phone

(###)

###

####

Where are you currently enrolled as a college student?

Our program is limited to current college students attending UT-Dallas, Dallas College, and surrounding schools.

What year are you in school?

Reason for Therapy

What has led you to seek a therapist? What are you seeking support for?

Previous Experience

Have you ever been in therapy before? If so - for how long, how many different therapists, etc.?

School Counseling Center

We encourage students to try their school counseling center before pursuing therapy via Wesley's program. Have you ever seen a therapist at the counseling at your college (i.e. like the UTD Counseling Center)? Why or why not? What made you reach out to us instead of pursuing therapy with the school counseling center? If you are on the waiting list or if you have already used up your free sessions, please share more about that.

What qualities, identities, or backgrounds do you want in a therapist? For example, some folks might seek out therapy with a woman, person of color, or someone with particular interests or specialties.

How did you learn about Synergy Wesley Foundation's therapy program for students?

Health Insurance

Do you have health insurance? If so, what company do you have? Do you know if they cover a portion of therapy sessions?

Insurance Use

Do you give permission for therapists in our program to file sessions to your insurance?

Yes

Sexual Orientation/Gender Identity

Religious Background / Denominational Affiliation

Racial Identity

Surveys

To support Synergy Wesley Foundation's grant reporting and applications for additional funding, I agree to submit regular surveys as requested by Synergy Wesley Foundation (up to one survey per month). These surveys will not ask for specific information from your therapy sessions, but general questions about how often you are utilizing therapy services, whether/how these services are benefitting you, and any other information relevant for our grant.

I agree to the above statement. I will submit surveys up to once per month, as requested by Synergy Wesley Foundation.

Disclosure

I agree that my responses may be shared with the Synergy Wesley Foundation Campus Minister (Brittany), and with therapists and staff affiliated with our Wesley Therapy Program. For grant reporting and application purposes (in order to request more funds for student therapy), we may also share general information about your identity and/or therapy needs with our granting partners (including Texas Methodist Foundation), but we will not disclose your name.

I agree to the above statement. You can share my information with Brittany and therapists as needed, and you can generally share about me with granting partners without using my name.

Release of Information

I agree that as a part of the Synergy Wesley Foundation therapy program, my therapist may need to connect with Synergy Wesley Foundation leadership about my sessions with them in order to secure payment for my sessions, report the number of sessions planned and attended, or for any other administrative matters. The content of individual student therapy sessions will be confidential, but therapists may be required to report generally about their work with students for grant and session payment purposes.

I agree to the above statement and to the Release of Information between my therapist and the Synergy Wesley Foundation Campus Minister and other relevant members of our team for the purpose of session payment, data collection, and grant reporting.

Session Cancellations

I agree to follow the cancellation policy guidelines set forth by my therapist, and I agree to give the required amount of advanced notice to my therapist if I need to cancel or reschedule my appointment. No-show and late cancellations may result in my dismissal from the free therapy program or a requirement to pay a portion of future sessions.

I agree to the above statement. I will respect my therapist and the free therapy program by honoring cancellation policies and giving adequate advanced notice. I understand that no-shows may result in my dismissal from the program.