Sista Afya Community Mental Wellness: Waitlist Form
Thank you for your interest in receiving therapeutic services at Sista Afya Community Mental Wellness. Please take 5 min. to fill out this form. When we have openings we will contact you.
If you have any questions, feel free to reach out us at:
Full Name (First, Last)
How did you hear about us?
What condition are you seeking therapy for?
Traumatic Stress (PTSD, Acute Stress)
What are focus areas do you need support with?
Career and Relationship Transitions
Handling Multiple Role Demands (i.e. mother, caretaker, etc.)
How long have you been living with your mental health challenges?
Less than a year
5 + years
Which Therapist are you interested in seeing?
How will you pay for services?
Self-pay (Out of Pocket/Sliding Scale)
Blue Cross Blue Shield PPO
We offer a sliding scale for self-pay clients that cannot pay a full fee. Would you be able to pay our starting rate of $40 per session?
Unsure at this time
Would you like to schedule a 15 min. phone consultation before scheduling an appointment?
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This form was created inside of Sista Afya.