Connection Form
Please complete the following information below to be connected with one of our therapists. Our Practice Manager will contact you soon to confirm your information and schedule your initial session. 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 address *
Office Location *
Last Name *
First Name *
Client's Name *
Client Date of Birth *
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Best Contact Phone Number *
Clinician Preference (Lenexa):
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Clinician Preference (Northland):
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Clinician Preference (Lee's Summit):
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Clinician Preference (St. Joseph)
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Clinician Preference (St. Louis):
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Please let us know if there is a specific therapy you are looking for?
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Please provide a brief description of what you are seeking counseling for. *
How did you hear about us? *
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