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: 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? *

Insurance & Payment Information

Please fill out the insurance information to the best of your knowledge. You must fill out this section if you are paying with insurance. The primary policyholder is the person who originally received health insurance coverage from an employer/company/plan. If you are doing self-pay you can skip this section.

Check off your method of paying for sessions? *

Blue Cross Blue Shield PPO (HMO & Medicaid not accepted)

Full rate: $120/session

Primary policy holder insured name *

Relationship to Primary Insurance Policy Holder: *

Self

Spouse

Parent

Primary Policy Holder Date of birth: * +

Primary Policy Holder Street Address *

Address Line 2 *

City *

State *

Zip Code *

Primary Policy Holder Phone Number *

Member ID Number *

Policy/Group number *

Attach image of front & back of insurance card

Attach image of your Photo ID (jpeg/png file only) *

Scheduling Preferences

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)? *

Yes

No

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

What Therapist are you interested in seeing? *

Melanie Clavelle LSW- Specialties: Women, Young Adults: Issue Areas: Self-esteem, depression, complex trauma, family issues, life transitions

Betty Hailu, LCSW - Women, Young Adults, Adults | Issue Areas: Depression, anxiety, trauma, adjustment difficulties, anger/conflict management, relationship issues, phase of life transitions.

Danielle Swan, MAATC - Specialties: Women, Adults | Issue Areas: Depression, Anxiety, Bipolar Disorder Women's Issues, Self-Esteem, Substance Use, Grief/Loss

NOT ACCEPTING NEW CLIENTS - CHOOSE OTHER THERAPISTAmber Kelley, LSW- Specialties: Women, Young Adults | Issue areas - Self-esteem, anxiety, trauma, challenging family situations, and life transitions.

NOT ACCEPTING NEW CLIENTS - CHOOSE OTHER THERAPISTApril Threatt, MA - Specialties: Women, Adults, Young Women| Issue Areas: Anxiety, Depression, Trauma, Communication Issues, Burnout, Phase-of-Life transitions, Self-esteem, Coping Skills, Women Issues

[Required] Schedule Intake Session

I understand that I must schedule a 15 min. intake session 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 below: *

Yes

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

I understand that insurance may not cover the full price of therapy services. I am responsible for paying the amount for therapy that insurance does not cover. I will be informed of my cost per session prior to my first appointment. If I am paying out of pocket, I am responsible for paying the full rate. *

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