Affinity Holistic Living Mental Wellness Fund: Partner Therapist Form

Affinity is addressing mental health disparities faced by Black LGBTQ+ people! We aim to de-stigmatize mental health needs, increase access to high quality services, and promote Black LGBTQ+ care providers by linking our people with qualified therapist of shared identities. The Holistic Wellness Mental Health Fund provides financial assistance for people seeking care for up to 8 sessions with our partner therapists.

Use this form to submit your infromation and be added to our Partner Therapist List.

Applications for people seeking Therapy will re-open in January 2023. If someone wants services from you an Affinity staff member will be reaching out with more information.

Affinity Community Services is a Black led, queer led organization on Chicago’s Southside dedicated to social justice in Black LGBTQ+ communities. For over 28 years, we have centered Black queer women through community organizing, intergenerational programming, education, and healing justice.

Learn more at affinity95.org

Contact Information

Name

First Name

Last Name

Pronouns

What pronouns do you like others to use when referring to you?

She/ Her

They/ Them

He/ Him

None

Other

Other Pronoun

If the pronouns that you like to use are not included in the previous question, please list them in the space above.

Verify Email

Phone

Do you have a preferred method of contact?

(check all that apply)

E-mail

Phone

Do you identify as Black/African-American in terms of your race/ethnicity?

Please indicate how you share identity with our clients, in terms of race/ethnicity?

Yes

Shared Identity: Gender

Please indicate the term that most closely describes how you identify with the LGBTQ+ community in terms of Gender

Transgender Woman/ Trans-Feminine

Transgender Man/ Trans-Masculine

Cisgender Woman

Cisgender Man

Non-Binary/ Gender- Fluid

Prefer not to answer

Other

Other Gender Identity

If the term for gender identity that you use was not included in the previous questions, please list it above.

Shared Identity: Sexuality

Please indicate the term that most closely describes how you identify with the LGBTQ+ community in terms of Sexuality

Lesbian

Bisexual

Queer

Gay

Heterosexual

Asexual

Prefer not to answer

Other

Other Sexuality

If the term for sexual identity that you use was not included in the previous questions, please list it above.

Professional Title

Are you licensed to practice in Illinois?

Or under the supervision of someone licensed to practice in Illinois?

Yes

Do you have capacity to meet with new clients for at least 8 sessions between February 2023 and May 2023?

Yes

Are you currently accepting new clients?

Yes

How will you be offering services?

In Person Only

Online Only

Both in person and online

Headshot

Please attach a headshot for inclusion in our mental health Partner Therapist List that will be shared with community members seeking services.

Bio

Please upload a short biography sharing information about yourself, your approach to mental health care, and specializations to be shared with community members seeking services in our Partner Therapist List

Proof of Insurance

Please upload a copy of your proof of insurance to provide therapy services.

I am comfortable with my name, photo, race, gender, and sexual identity, being shared in Affinity's public Resource Directory.

Yes

I am comfortable with my name, photo, race, gender, and sexual identity, being shared in Affinity's public Resource Directory.

Yes, my information can be shared in the public directory.

No, my information can only be shared directly with applicants seeking therapy through a private link.