Therapy Request Form

Request edit access

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Thank you for your interest in therapy through Dandelion Therapy (Child Play Therapy and Parent Support and Individual Therapy). A good fit is very important to the success of therapy and your answers will help me determine if we are the right therapy practice for you. You can email me directly at hello@DandelionTherapyLLC.com if you have questions.

Our website is: www.DandelionTherapyLLC.com

**If you are having a mental health emergency, please use the following resources:**
911 or 988 - emergency police and suicide hotlines
1-855-265-3598 - mental health emergency
Go to your nearest emergency room

Today's Date *

YYYY

Email *

Okay to email you? *

Yes

Phone #

Okay to call and leave a voicemail if you don't answer? *

Yes

Your Name *

Child's Name

Child's Age

Address (City and State)

Insurance / Payment (Below is all that we accept) *

BCBS

Aetna

Kancare Sunflower (Medicaid)

Kancare United Healthcare (Medicaid)

Kancare Healthy Blue (Medicaid)

Private Pay (we can provide a superbill for possible reimbursement for out-of-network)

Other:

Required

Briefly describe why you are seeking therapy services at this time *

Please continue to look for services while you wait.

https://www.psychologytoday.com/us/therapists?search=lawrence,+ks

Thank you!

I will contact you when we have availability or will direct you to alternate resources if we are not a good fit for your current needs. I may also contact you to let you know the approximate wait time if nothing is listed here.

Wait Time = none (as of April 11th, 2026)

hello@DandelionTherapyLLC.com

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