Read below before completing this form:

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 - Do not use a phone. 

Please take 10 minutes to fill out this form for those seeking free therapy. Please have your photo ID and proof of income or public assistance ready to upload to this form for proof of Illinois residency.

Lastly, make sure that you schedule your 15-minute phone intake at the link on our website: www.communitycare.sistaafya.com/therapy

If you forget this step you will not be able to complete the process to begin therapy.

 

Eligibility: You must make less than $1700 a month to be eligible for services and provide proof of that before starting the Thrive in Therapy program. 

 

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 at Sista Afya Community Mental Wellness 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: saccintake@sistaafya.com. NO PHONE CALLS PLEASE!

Basic Demographics

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Gender *
Race (select all that apply) *
 
How did you hear about us? (select all that apply) *
 
Relationship status *
 
Employment status *
 

Mental Health Background Information

Have you received therapy before? *
Have you ever received therapy services from Sista Afya Community Care or Sista Afya Community Mental Wellness? *
What mental health condition are you seeking therapy for? *
 
What issue areas do you need support with? (Check all that apply) *
How long have you been living with mental health concerns? *
Were you recently hospitalized for a mental health crisis in the last 6 months? *
Do you have a history of self-harm or suicidal thoughts? *

Eligibility and Income Requirements

The Thrive in Therapy program provides free therapy for people making less than $1700 a month which is 150% of the federal poverty guideline for a single person. Below you will  be asked to provide proof that you make no more than $1700 a month. Please upload proof of income including paystubs, unemployment, public assistance letters, or any other form of documentation that verifies your income. You must have your ID providing proof of residency in Illinois ready to upload. Please have these documents to fill out this form completely.
Do you receive public assistance? (LINK, Section 8, Medicaid etc.) If yes, please specify what assistance you receive below.
 


Therapist + Scheduling

Disclaimer - Family & Friends Policy:We understand that people often find out about our program often from other individuals who are or were seeking services with Sista Afya Community Care. We want to respect confidentiality and give you the best services possible. So if you know someone who has received or is receiving services, please let us know so that we do our best to not assign you to the same therapist. Please note this is to avoid any conflicts of interest. *
What Therapist are you interested in seeing? If you see a Therapist that is not accepting new clients, choose another Therapist is available. *
What time are you available for a therapy session? *
 MondayTuesdayWednesdayThursdayFriday
Morning ( 9 AM - 12 PM)
Afternoon (12 PM- 4 PM)
Evening ( 4 PM- 7 PM)

Program Agreement

PROGRAM AGREEMENT

The Thrive in Therapy Fund Program focuses on improving the mental wellness outcomes of women through increasing access to quality mental wellness services in Illinois.

1.1 Guidelines

Thrive in Therapy Fund 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 Fund 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.

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. I understand that I must schedule therapy sessions in advance through Simple Practice or by contacting my Therapist.

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

Your 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 sliding scale or refer out to another provider. This allows us to provide therapy services for those who cannot pay out of pocket.

1.4 Telehealth Therapy

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.

1.5 Late Cancellations and No-Shows

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.

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.
Sign below: *
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