Connection Form
Please complete the following information below to be connected with one of our therapists. Our Client Care Coordinator will contact you soon to confirm your information and schedule your initial phone consultation. For weekend requests, she will contact you on Monday morning. Your responses will not be shared outside of Embark Counseling Services. The data contained in this form will not be used exclusively to establish your connection with the best therapist for your needs, or the therapist you requested.
Email *
Office Location *
Last Name *
First Name *
Client's Name *
Client Date of Birth *
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Best Contact Phone Number *
Home Address *
Which method of communication do you prefer? *
Clinician Preference (Lenexa):
Clear selection
Clinician Preference (Northland):
Clear selection
Clinician Preference (Lee's Summit):
Clear selection
Clinician Preference (St. Joseph)
Clear selection
Please let us know if there is a specific therapy you are looking for?
Clear selection
Please provide a brief description of what you are seeking counseling for. *
If you do want to use commercial or medicaid insurance, please let us know below your insurance company. Not all clinicians are credentialed with the plans below. Our Client Care Coordinator will help you find the right fit! *
How did you hear about us? *
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