Therapist Form — Synergy Wesley Foundation

Name

First Name

Last Name

Pronouns

Phone Number

What excites you about working with college students?

Can you share in 1-2 sentences what made you say yes to this, and what makes you care about providing therapy with college students?

Number of Students

How many students/sessions per month seems doable for you right now? A ballpark range is fine.

Your preferred clients (confidential)

What directees do you like to work with? Do you have any preferences about who we should try to refer to you? For example, if you prefer to work with BIPOC or queer clients, please share that here. We will do our best to find the best fit for both therapists and students. (Note: This is for the purposes of our referrals, and it will not be shared with students or publicly).

Bio for Students

A 200-ish word bio geared towards college students - they will probably appreciate hearing about your identity, background, where you went to college, and any stories or experiences from college that shaped who you are or the work you do. They would probably like to hear what spiritual direction sessions might look like with you (bonus points for concrete examples that help paint a picture for them).

Social Media/Website

Can we make a post about you and feature you on our instagram, facebook, and website?

Yes, go for it

Yes, but I'd like to read it and approve it first

Bio for social media/website

A short, 60-75-ish word bio for our social media that does not necessarily have to be geared towards college students

Sexual Orientation/Gender Identity

If you're comfortable, share anything relevant about your sexual orientation/gender identity; if you don't identify as LGBTQ, how are you working to be an Ally to LGBTQ folx?

Racial Identity/Ethnicity

Share anything about your racial identity, ethnicity, cultural background - anything that helps the students to know you better. For white folx, how are you working to be an ally to Black and Indigenous people of color?

Liability Insurance

Do you or your practice have active/current liability insurance coverage for yourself as a therapist?

Yes

I will renew it before working with students

Any other notes/comments/info. you want to add.

Do you accept client health insurance?

Yes or No / If yes, please list the health insurance companies you are in-network with here:

Payment

How do you typically charge clients for sessions?