JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Accepting New Clients for General Counseling, Dietitian Services, Interns, Marriage, Adult & Adolescent Anxiety IOP Groups
Please fill out the following information to help us better assess which counselor is the best fit. After receiving your submission, someone will be in contact by the next business day to set up an appointment. If you have any trouble with this form call Renew at 913.768.6606 and press 0.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Location
*
Olathe
Lawrence
Required
FYI about Insurance and Mental Health Service
The Anxiety Intensive Outpatient Programs for both Adults and Adolescents are covered by many insurance providers.
However, the majority of individual clinicians at Renew (and many other counseling centers) do not take insurance, but will create a "superbill" that you can submit and be reimburse by your insurance company. Click here to learn more about the benefits of not using your insurance for mental health services and how to utilize your Out-of-Network Benefits.
https://renewkc.com/faq/
Seeking Group Therapy (not individual, couple or family) use these links
* Adult IOP: Request a Free Assessment:
https://docs.google.com/forms/d/e/1FAIpQLSe4xdm7qMpTkwMjtNEgX8FcnSbRT_pmKOD0ilNVyOfSehc5MQ/viewform
* Adolescent (12-18) IOP for Anxiety/Depression: Request a Free Assessment:
https://docs.google.com/forms/d/e/1FAIpQLScyEu4CCzcLChEveLDnEyAVYrb3SWEqO7kToI7NExLa_56EEA/viewform
Your Name
*
Your answer
Your relationship to the client:
*
Self
Parent
Physician's Office
Spouse
Other:
Client's Name (if other than yourself)
Your answer
Client's Age
*
Your answer
Desired Services:
Individual Counseling
Family Counseling
Couples Therapy
Dietitian Services
Adult Intensive Outpatient Program for Anxiety:
https://goo.gl/forms/5ncy3O0yN8v6JwFm1
Adolescent (13-18) Intensive Outpatient Program for Anxiety:
https://forms.gle/YkWvzor2Hpy5KLow6
Group Therapy
Equine Assisted Psychotherapy
Reduced Fee Student Intern (learn more at:
https://renewkc.com/counseling/
)
Other:
Best Contact Number?
*
Your answer
May we leave a voice message?
*
Yes
No
E-mail Address
Your answer
Preferred method of contact? (i.e. phone call, text, email)
*
Your answer
Payment Preference?
*
Insurance
Private Pay
If insurance, what insurance provider?
Your answer
If insurance, are you willing to use your out-of-network benefits to insure best therapist?
Yes
No
Clear selection
Are you interested in seeing one of our graduate intern counselors for a significantly reduced fee? Intern counselors are supervised weekly by seasoned therapists and provide excellent counseling at a reduced rate.
Yes
No
Clear selection
Who referred you?
Doctor
Therapist
Facility
Friend
Other:
May we contact the person who referred you to thank them?
Yes
No
Clear selection
Name of person who referred you:
Your answer
Please describe the primary reasons you are seeking counseling support for yourself or someone else:
Your answer
Is there anything else you think would be important for us to know?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Renew Counseling Center.
Report Abuse
Forms
