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Affinity Holistic Living Mental Wellness Fund: Partner Therapist Form

Affinity is addressing mental health disparities in the Black LGBTQ+ by increasing access to mental health services by linking people with 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 be added to our Partner Therapist List.

Affinity Community Services is a Black led, queer led organization on Chicago’s Southside dedicated to social justice in Black LGBTQ+ communities. For 25 years, we have centered Black queer women through community organizing, intergenerational programming, education, and healing justice. 
Learn more at affinity95.org
Contact Information
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First Name
Last Name
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What pronouns do you like others to use when referring to you?

If the pronouns that you like to use are not included in the previous question, please list them in the space above.
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(check all that apply)
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Please indicate how you share identity with our clients, in terms of race/ethnicity?
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Please indicate the term that most closely describes how you identify with the LGBTQ+ community in terms of Gender

If the term for gender identity that you use was not included in the previous questions, please list it above.
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Please indicate the term that most closely describes how you identify with the LGBTQ+ community in terms of Sexuality

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

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Or under the supervision of someone licensed to practice in Illinois?
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Please attach a headshot for inclusion in our mental health Partner Therapist List that will be shared with community members seeking services.

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

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