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 and are Medicaid Recipients. Please have your photo ID and Medicaid Card 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 be a Medicaid recipient and have one of the following MCO plans to receive services: Meridian, Blue Cross Blue Shield Community, Molina, and Aetna Better Health. 

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 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? *

Medicaid Plan Information

Which Medicaid MCO Plan do you have? *


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? *
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


1.1 Guidelines

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 your Medicaid plan. 

If your Medicaid plan changes, you must let the Intake Assistant know immediately. 

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 be moved to the bottom of the waitlist and have to start the intake process over again.

1.6 Termination

I understand that I can terminate participation in mental health services at any time. 

Affix your signature electronically below to signify agreement with the terms and conditions of this agreement.
Sign below: *
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