Therapy Interest Form
At TherLively, we want you to get the best therapy for you. After you've read through our website and policies on the "FAQs" page, please complete the questions below. This is the first step in making sure we're a good fit for you. 

Make sure to complete all questions, scroll to the very bottom of the form, and click the submit button at the end. (Otherwise, we will not get your responses.) 

If you haven't heard from us within 48 business hours, your form was probably not submitted. Please contact us by phone at 817-381-5259 or email at admin@TherLively.com to let us know. We apologize in advance for any inconvenience.
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First and last name *
Best email address to reach you *
Best phone number to reach you *
What is your preferred contact method? *
We'll do our best to reach out to you through your preferred contact method first, then follow-up through other methods of communication if we're unable to reach you.
State and city where you currently live (e.g. Dallas, TX) *
Your age *
How did you hear about us?
Please briefly describe what you want to focus on in therapy *
Please check all that apply to you *
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Scheduling: Time of day

Therapy appointments at TherLively tend to occur from 9am-4pm Monday through Thursday and 9am-1pm on Friday. Please check the times you can be available for a regularly scheduled appointment on a weekly basis. (The more availability and flexibility you have, the more likely and sooner we will have availability to meet with you.)
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(Please know that if you schedule an intake appointment with a therapist at TherLively, it is unlikely the intake appointment will occur at your regularly scheduled time. The longer duration of intake appointments and our efforts to get you in for an intake appointment to start therapy sooner rather than later make it challenging to ensure the same time. Again, the more flexibility you have with scheduling an intake appointment, generally the sooner we can schedule with you.) 
Required
Scheduling: Day of week

We understand some days of the week might work better for you, depending on when you work from home, are in the office, have childcare, or tend to travel. Please check the days of the week you can be available for a regularly scheduled appointment on a weekly basis.
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Required
Scheduling

Please let us know anything about your schedule we might have missed.
In-Person and Online Therapy *
Online Therapy

We offer online therapy and in-person therapy in Southlake, Texas. Even if you prefer in-person therapy, there might be occasions when you or your therapist are only able to meet virtually. Please confirm that you have a private place to meet for therapy sessions and a strong internet connection for virtual therapy.
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Required

Fees & Payment

Your first appointment with your therapist is an intake appointment. Intake appointments at TherLively are $300 (and typically last about 80 minutes). Most therapy sessions usually last about 45-50 minutes; the rate for a 45-50 minutes therapy session is $250. 

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We want to provide the best possible care to you, and not accepting insurance is how we’ve managed to do that at TherLively. Payment is due by the time of your appointment. We accept most major credit cards. You can also use your HSA/FSA card to pay for therapy sessions. You may let your therapist know if you would like to receive a detailed receipt (superbill) on a monthly basis to assist you in seeking out-of-network reimbursement with your health insurance provider. 

(Medicare participants: effective January 1st 2024, TherLively and all its providers have chosen to opt-out as a Medicare provider. Therefore, all session fees are due at the time of service and may not be submitted for reimbursement through Medicare or any related supplemental coverage. If you’d like to use your Medicare coverage for counseling services, you must locate a provider affiliated with Medicare.)

Required
Medicare

Are you a Medicare participant?
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Cancellation Policy

We ask you to let us know as soon as you can if you need to cancel an appointment. No shows and appointments canceled less than 48 hours in advance will be charged the full appointment fee. 

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When you schedule an appointment at TherLively, we reserve that time slot for you and tell other clients they cannot meet with their therapist at that time. We've found this cancellation policy helps to enable clients to meet with their therapist when their therapist has availability. It also honors the time of our therapists, ensures the health of our practice, and discourages cancellations caused by avoidance when doing exposure work (which can be counterproductive to your therapy goals). 

Required

Emergency or Crisis

If you are currently experiencing an emergency or crisis please immediately call 911 or go to the nearest emergency room. 

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TherLively does not provide 24-7 care. We are a small, private practice and unable to provide emergency services. 

Required
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