Thank you for your interest in receiving mental wellness care at Sista Afya Community Mental Wellness. You must be a permanent Illinois resident and above the age of 18 to receive therapy at our organization. Please be prepared to upload an image or document of your proof of income and your ID to complete this form. We recommend using a desktop or laptop to complete this form. 

 

Please take 10 minutes to fill out this form for a sliding scale therapy session. You must make less than $3500 a month to be eligible for sliding scale discount and provide proof of income.  At the end of this form, you must schedule a 15-minute intake session with your Therapist of choice to schedule you for an appointment, to review therapy policies, and to answer any questions you have. 

 

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

 

If you are paying with insurance or are applying for the free therapy program, please fill out the Therapy Request form for free therapy or insurance on our website. Please note that free therapy slots are limited and may not be readily available. Visit: www.sistaafya.com/therapy

 

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

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Marital status *
Gender *
What mental health condition are you seeking therapy for? *
 
How did you hear about us? (Check all that apply) *
Have you been to therapy before? *
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? *
What issue areas do you need support with? (Check all that apply) *
 

Scheduling Preferences, Payment, & Fees

Payment & Fees
Please select your monthly income level and payment per session. *


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

[Required] Choose Therapist + Schedule Intake Session

When are you available for a therapy session? (Check all that apply) *
 MondayTuesdayWednesdayThursdayFridayNot Available
Morning (9 AM - 12 PM)
Afternoon (12 PM - 4 PM)
Evening (4 PM - 7 PM)
What Therapist are you interested in seeing? *
I understand that I must schedule a 15 min. intake session with a Therapist before receiving services. Failure to complete an intake session will result in not being seen for therapy. You can schedule your intake session by clicking the scheduling link next to your Therapist of choice in the next section. *
Select your Therapist of choice to schedule your 15 min. intake session:
 
Betty Hailu, LSW - https://calendly.com/betty-therapist 
 
Danielle Swan, MAATC - https://calendly.com/danielle-therapy
 
April Threatt, MA: https://calendly.com/april-therapy
 
 
 
 
Please read our policies below affirming that you understand the requirements.
Friends and Family Policy: We can not see people within the same family or friend group for therapy to protect confidentiality in the client-therapist relationship. Please affirm that you do not have a family member or friend that is seeking therapy at Sista Afya Community Mental Wellness. *
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. *

Completion

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