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:


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

Marital status *
Gender *
What mental health condition are you seeking therapy for? *
How did you hear about us? (Check all that apply) *
Do you have a history of self-harm or suicidal thoughts? *
Were you hospitalized for a mental health crisis within the last 6 months? *
How long have you been living with mental health concerns? *
Have you been to therapy before? *
What issue areas do you need support with? (Check all that apply) *

Company Information

Which EAP company are you receiving benefits from? *

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? *
When are you available for a therapy session? *
 MondayWednesdayThursdayFridayNot Available
Afternoon (1 PM - 4 PM)
Evening (4 PM - 7 PM)
What Therapist are you interested in seeing? *
[Required] Sign up for a 15 minute phone intake session:

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. *
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. *


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