Contact Information
Please fill in the following contact form to be contacted for a phone consultation. 
IMPORTANT: Please be sure to check your email and junk folder. Allow 72 business hours for me to receive your info and contact you back. Note: vacations and holidays may delay my response.
Sign in to Google to save your progress. Learn more
Email *
First and Last Name of Client/Parent or Guardian of Client *
How often are you looking to meet? Note: I recommend weekly or bi-weekly to start.  *
State of Residence of Client/Parent or Guardian of Client *
Phone Number *
Email You Check Regularly *
First and Last Name of Child Client (If applicable, otherwise type "N/A") *
I will need permission from all custodial parents to consent for therapy. Are you able to provide this? (If this does not apply, check "N/A.") *
Client's Age *
Pronouns of Client *
How did you hear about me? *
Word of Mouth Referral *
What timeframe are you looking to begin therapy. *
Preferred Times to Meet (within my business hours: Wed: 6pm-9pm (virtual), Thu: 3pm-8pm (in office), Fri: 11am-7pm (in office)) *
Would you like to meet virtually or in person? (Note: The virtual option is for Kansas adult residents only. At this time, kids must come in person.) *
Check "yes" that you understand that I only accept the following forms of payment:



American Express


Flexible Spending Account (FSA)

Health Savings Account (HSA)

KS Medicaid

What type of insurance do you have (primary and if applicable, secondary)? (Please note: From previous question, I currently only accept KS Medicaid or private pay. I can provide a monthly superbill for you to submit to your insurance for reimbursement after you pay for sessions. I cannot guarantee they will pay any reimbursement, and it is subject to your deductible/coinsurance.) *
Briefly describe the client's therapy needs here. What led you to seek therapy now? What are your goals? *
Has the client been in therapy before? If yes, when? *
Does the client have any mental health diagnoses? If yes, what? *
Is the client seeing a psychiatrist? Taking medication? If so, which ones? *
Any suicidal or homicidal thoughts? If so, how long ago? Please note: I do not review this form instantaneously, and thus will not see this right away. If you are in crisis, please seek help from emergency services, contact the National Suicide Prevention Lifeline at 988, or text the crisis text line, "HOME" to 741741. *
Any prior psychiatric hospitalizations? If yes, when? *
Any hallucinations (seeing or hearing things that are not real)? If yes, what/when/frequency? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Tamicka Monson Counseling LLC. Report Abuse