Thank you for your interest in receiving mental wellness care at Sista Afya Community Care through our Thrive in Therapy program. You must be a permanent Illinois resident and above the age of 18 to receive therapy at our organization. We recommend using a desktop or laptop to complete this form.

Please take 10 minutes to fill out this form for those seeking free therapy. Please have your photo ID ready to upload to this form for proof of Illinois residency. You must make less than $1500 a month to be eligible for services and provide proof of that before starting the Thrive in Therapy program. After completing this form, your Therapist will email you to 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 paying sliding scale, please fill out the Therapy Request form for sliding scale or insurance on our website. Please note that sliding scale 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: communitycare@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: * +

Age *

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? *

Have you ever received therapy services from Sista Afya Community Care or Sista Afya Community Mental Wellness? *

Yes - You are not eligible for services

No

Have you been to therapy before? *

Yes

No

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

Yes

No

Were you recently hospitalized for a mental health crisis in 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

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? *

Please upload a picture of your photo I.D. *

Upload Proof of Income or Public Assistance Letter *

Scheduling Preferences

I understand that these therapy sessions are provided virtually. To receive Telehealth services, I must have a private, quiet space with a secure internet connection for therapy. If I am in public or driving, the therapy session will be canceled by my Therapist and it will count towards my late cancellations. *

Yes

What Therapist are you interested in seeing? *

Madison Sparkman, BA (Intern) Specialties: Young adults, women, students, sexual minorities Issue Areas: Women’s issues, trauma, depression, anxiety, life transitions, stress management, coping skills, self-esteem, LGBTQIA+

NOT ACCEPTING CLIENTS - CHOOSE OTHER THERAPIST. Tiana Hill, LCSW- Specialities: Young Adults, Women, Adults Issue Areas: Trauma, depression, anxiety, women's issues, health issues, financial wellness, self-esteem, social justice, LGBTQ+ issues.

NOT ACCEPTING CLIENTS - CHOOSE OTHER THERAPIST: Candice Gant, LCSW - Specialties: Young Adults, Women, Adults, Trauma, Anxiety, Depression, Interpersonal violence, substance use, financial wellness, and interpersonal difficulties.

If you selected Madison, when are you available for a therapy session?

	Tuesday	Thursday
Day Time (12 PM - 5 PM)	Tuesday	Thursday

If you selected Tiana, when are you available for a therapy session?

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

NOT ACCEPTING NEW CLIENTS -If you selected Candice, when are you available for a therapy session?

	Monday	Tuesday	Wednesday	Thursday	Friday	Not Available
Morning (9 AM - 12 PM)	Monday	Tuesday	Wednesday	Thursday	Friday	Not Available
Afternoon (12 PM - 5 PM)	Monday	Tuesday	Wednesday	Thursday	Friday	Not Available

[Required] Schedule Intake Session

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. A Therapist will contact you via email with information about completing the 15 min. intake. *

Yes

Organizational Policies

Please read our policies below affirming that you understand our requirements for the Thrive in Therapy program.

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 Care. *

Yes

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

I understand that if I am approved for free therapy services, that I will have up to 24 free therapy sessions to be used within 6 months with a Sista Afya Therapist. *

Yes

I understand that if I am approved for free therapy services that I can miss no more than 3 therapy sessions. If I miss more than 3 therapy sessions, I will no longer be able to receive free therapy from Sista Afya Community Care. Please select yes to affirm your understanding of this requirement. *

Yes

I understand that I must provide proof of income or public assistance to receive free therapy at Sista Afya Community Care. Lack of proof of income or public assistance will result in ineligibility for services. *

Yes

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