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.
FYI about Insurance and Mental Health Service
The Anxiety Intensive Outpatient Programs for both Adults and Adolescents are covered by many insurance providers.

However, the majority of individual clinicians at Renew (and many other counseling centers) do not take insurance, but will create a "superbill" that you can submit and be reimburse by your insurance company. Click here to learn more about the benefits of not using your insurance for mental health services and how to utilize your Out-of-Network Benefits. https://renewkc.com/faq/

* Adult IOP: Request a Free Assessment: https://goo.gl/forms/5ncy3O0yN8v6JwFm1
* Adolescent (12-17) IOP for Anxiety: https://anxietycenterkc.com/adolescent-program/
Your Name *
Your relationship to the client: *
Client's Name (if other than yourself)
Client's Age *
Desired Services:
Best Contact Number? *
May we leave a voice message? *
E-mail Address
Preferred method of contact? (i.e. phone call, text, email) *
Payment Preference? *
If insurance, what insurance provider?
If insurance, are you willing to use your out-of-network benefits to insure best therapist?
Clear selection
Are you interested in seeing one of our graduate intern counselors for a significantly reduced fee? Intern counselors are supervised weekly by seasoned therapists and provide excellent counseling at a reduced rate.
Clear selection
Who referred you?
May we contact the person who referred you to thank them?
Clear selection
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?
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