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 relationship to the client:
Client's Name (if other than yourself)
Adult Intensive Outpatient Program for Anxiety
Adolescent (12-17) Anxiety Intensive Outpatient Program (coming Fall 2018)
Best Contact Number?
May we leave a voice message?
If insurance, what insurance provider?
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:
Please describe the primary reasons you are seeking counseling support for yourself or someone else:
Is there anything else you think would be important for us to know?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service