Thank you for your interest in receiving therapeutic services at Sista Afya Community Mental Wellness. You must be a permanent Illinois resident and above the age of 18 to receive therapy at our practice. We recommend using a desktop or laptop to complete this form.

Please take 5 minutes to fill out this form for those paying for therapy with an EAP company.

ATTN: We do not provide individual therapy for couples and families. If you are looking for a couple's or family therapist, please review our Preferred Providers List at: http://bit.ly/afyaresources

If you have any questions, feel free to reach out to us at: therapy@sistaafya.com . NO PHONE CALLS PLEASE!

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of birth: * +

Marital status *

Gender *

Female

Male

Non-binary

Prefer not to say

What mental health condition are you seeking therapy for? *

Depression

Anxiety

Trauma Trauma

How did you hear about us? (Check all that apply) *

Do you have a history of self-harm or suicidal thoughts? *

Yes

No

Were you hospitalized for a mental health crisis within the last 6 months? *

Yes

No

How long have you been living with mental health concerns? *

Less than a year

1-5 years

5+ years

Have you been to therapy before? *

Yes

No

What issue areas do you need support with? (Check all that apply) *

Why are you seeking therapy at this time? What are your mental health concerns? *

Scheduling Preferences

Due to the COVID19 pandemic, we are only offering online video counseling for people to access our Therapists at their convenience with a connection to a mobile device or computer. Are you interested in receiving online video counseling sessions? *

Yes

No

When are you available for a therapy session? *

	Monday	Wednesday	Thursday	Friday	Not Available
Afternoon (1 PM - 4 PM)	Monday	Wednesday	Thursday	Friday	Not Available
Evening (4 PM - 7 PM)	Monday	Wednesday	Thursday	Friday	Not Available

What Therapist are you interested in seeing? *

Camesha Jones, LCSW - Women, Young Adults Issue Areas: Self-esteem, depression, anxiety, burnout, social justice, career challenegs, stress management, life transitions.

[Required] Sign up for a 15 minute phone intake session:https://calendly.com/sistaafyatherapy

Practice Policies

Paperwork: I understand that I must complete all paperwork sent to me through the client portal before beginning therapy. If my paperwork is not complete at least 2 days in advance, my appointment will be canceled. *

Yes

Late Cancellation/No-Show Policy: I understand that I will be charged a fee of $40 if I am more than 15 minutes late for an appointment, cancel within 24 hours of the appointment, or no-show to the appointment. The $40 will be deducted automatically from my card on file and is non-refundable. *

Yes

No

Completion

I certify that the information I have provided above is accurate to the best of my knowledge. *

clear

Single	Married	Divorced	Widowed
Long-term Relationship

Company Information

Scheduling Preferences

Practice Policies

Completion