Therapy Request Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in therapy through Dandelion 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

Curative

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 *

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.

hello@DandelionTherapyLLC.com

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Dandelion Therapy LLC.

Does this form look suspicious? Report

Forms