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Client Intake Form
Please complete prior to your assessment for the Adult Intensive Outpatient Program. This takes about 30 minutes to complete. You will need your insurance card to complete it if using insurance. Please take your time.
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* Indicates required question
*
Option 1
I'm seeking Intensive Outpatient services at
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The Anxiety Center at Renew Counseling provides services in both Olathe and Lawrence, Kansas. Please let us know where you are seeking services or if interested in first availability. Thanks.
Olathe
Lawrence
First Available
Legal First Name (on insurance card)
*
Your answer
Last Name
*
Your answer
Middle Initial
Your answer
Preferred Name
Your answer
Gender Stated on Your Insurance
*
Female
Male
Self-Identified Gender (if different)
Female
Male
Other:
Clear selection
Preferred Pronouns
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Email
*
Your answer
Race/Ethnicity (optional)
African American/Black
Asian
White
Hispanic/Latino (Ethnicity)
Native (American or Alaskan)
Native Hawaiian or Other Pacific Islander
Other:
Clear selection
Driver's License:
Your answer
Cell Phone (Please include dashes.)
*
Your answer
Can we text this number?
*
Yes
No
Required
Can we leave a voicemail at this number?
*
Yes
No
Required
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