Renew New Client Submission
Please fill out the following information to help us better assess which counselor is the best fit. After receiving your submission, someone will be in contact by the next business day to set up an appointment. If you have any trouble with this form call Renew at 913.768.6606 and press 0.
Your Name *
Your answer
Your relationship to the client: *
Client's Name (if other than yourself)
Your answer
Client's Age *
Your answer
Desired Services:
Best Contact Number? *
Your answer
May we leave a voice message? *
E-mail Address
Your answer
Payment Method? *
If insurance, what insurance provider?
Your answer
If insurance, are you willing to use your out-of-network benefits to insure best therapist?
Who referred you?
May we contact the person who referred you to thank them?
Name of person who referred you:
Your answer
Please describe the primary reasons you are seeking counseling support for yourself or someone else:
Your answer
Is there anything else you think would be important for us to know?
Your answer
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