Request for Intake Appointment
You have requested an initial intake appointment to begin therapy with a therapist at PHS (Psychological Health Services, LLC).  Please complete this form to provide the information we need to reserve an initial intake appointment time.  We will respond by text message to confirm availability and provide an appointment time.  

For initial intake appointments please plan for a longer, 1.5 hour session.  For minors, a parent/legal-guardian must attend the full intake session.  
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Full name of client appointment is scheduled for: 
For couples therapy- please list the full name of both members of the couple
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Date of birth for client appointment is scheduled for: *
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Minors- Name of all legal guardians/parents:
**Please note that only LEGAL parents or guardians may schedule and consent to mental health treatment. Ensure that the parents listed below have legal custody and right to consent. 
How did you learn about PHS ? *
Date & time of appointment you are requesting to reserve if you have been provided one by our staff OR best time of day for appointments. ***Please note that we do not have after 5pm or weekend times available. *
Type of appointment you are requesting: *
Brief description of what client seeking therapy is needing to work on. *
Phone # of client seeking appointment (parent or guardian phone if client is a minor) *
Can we leave text and voicemail at the above number? *
Email Address (parent or guardian email if client is a minor) where link to Client Portal & Intake Paperwork can be sent: *
Insurance Provider- if you will be using insurance for services (type NONE if you are not using insurance): Rate Information HERE. *
Do you (the client seeking treatment) live in the state of Kansas? *
Does the client seeking treatment have any plan of self-harm or suicide?  **If yes, please go to your nearest emergency room and do not await response. *
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