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) *
Your answer
Phone Number *
Your answer
E-mail Address *
Your answer
How did you hear about us? *
What condition are you seeking therapy for? *
What are focus areas do you need support with? *
How long have you been living with your mental health challenges? *
Which Therapist are you interested in seeing? *
How will you pay for services? *
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? *
Would you like to schedule a 15 min. phone consultation before scheduling an appointment? *
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