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 for Teens program. You must be a permanent Illinois resident 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 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/teens

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

Eligibility: Your teen girl must be an Illinois resident between the ages of 13-17 to receive 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) *
 
Parent Relationship status *
 
Parent Employment status *
 

Mental Health Background Information

Has your teen received therapy before? *
What mental health condition are you seeking therapy for, for your teen? *
 
What issue areas does your teen need support with? (Check all that apply) *
How long have they been living with mental health concerns? *
Was your teen recently hospitalized for a mental health crisis in the last 6 months? *
Does your teen have a history of self-harm or suicidal thoughts? *

Proof of Illinois Residency

Do you receive any of the follow public assistance or benefits (Check all that apply)? *
 

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 is your teen available for a therapy session? *
 MondayTuesdayWednesdayThursdayFriday
Morning ( 9 AM - 12 PM)
Afternoon (12 PM- 4 PM)
Evening ( 4 PM- 7 PM)
Do you want your teen to receive therapy in-person or online? *

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 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.

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 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.
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