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 10 minutes to fill out this form for those paying for therapy with Insurance and self-pay at our full rate. Please have your insurance information ready to list your member ID, group number, and upload a picture of the front and back of your insurance card. We only accept PPO plans at this time. 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 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 are not paying with insurance or cannot pay our full rate, please fill out the Therapy Request form for sliding scale or free therapy on our website.
If you have any questions, feel free to reach out to us at: email@example.com . NO PHONE CALLS PLEASE!