PROGRAM AGREEMENT
The Thrive in Therapy Program focuses on improving the mental wellness outcomes of women through increasing access to quality mental wellness services in Illinois.
1.1 Guidelines
Free Therapy
Thrive in Therapy is funded by individuals, organizations, and donors through Sista Afya Community Care, NFP. You will be required to report your experience using our services and funding for therapy to Sista Afya Community Care and our Donors at the end of your term. Your evaluation will be kept confidential.
Thrive in Therapy participants will have access to 8 free therapy sessions that must be used within 3 months. At the end of the 8 sessions, you will be assessed as to whether you need additional time in therapy.
Reduced Fee Therapy
Our session rate for reduced-fee therapy is $50. Payments are due at the time of service. You will be required to keep your credit/debit card on file in our system to charge your card. If your card declines, we will email you to notify you of the outstanding balance. If we do not receive your payment within 1 week, we will cancel your next scheduled therapy session until the balance is cleared.
I understand that I must complete all paperwork for therapeutic services including but not limited to: demographic information, informed consent for psychotherapy, privacy practices, and practice policies before beginning psychotherapy.
1.2 Privacy
Your participation with Sista Afya Community Care is confidential. We do not share your information with anyone outside of our donors for group reporting purposes.
1.3 Payment of Services
Free therapy sessions are paid in full by our donors.
If your income increases, and you are able to pay for therapy services. You must notify your Therapist so we can discontinue services and set you up with a reduced fee or refer out to another provider. This allows us to provide therapy services for those who cannot pay out of pocket.
Reduced Fee Therapy
Our session rate for reduced-fee therapy is $50. Payments are due at the time of service. You will be required to keep your credit/debit card on file in our system to charge your card. If your card declines, we will email you to notify you of the outstanding balance. If we do not receive your payment within 1 week, we will cancel your next scheduled therapy session until the balance is cleared.
1.4 Telehealth TherapyI 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.1.5 Late Cancellations and No-Shows
Free Therapy
I understand that I can have no more than 3 late cancellations or no-shows for therapy. After the 3rd late cancellation or no-show I will lose access to the Thrive in Therapy Fund program and will not be able to access services from Sista Afya Community Care.
Reduced Fee Therapy
If you are paying a reduced fee for therapy the late cancellation/no-show fee is $50 per occurrence.
1.6 Termination
I understand that I can terminate my participation in Thrive in Therapy Fund participation at any time. Please contact your Therapist if you decide to terminate your free therapy sessions.
Affix your signature electronically below to signify agreement with the terms and conditions of this agreement.