Request Talk Therapy Services
Thank you for reaching out! This form helps us understand you, your child, or your family and the support you’re hoping for. Your answers guide our intake and waitlist process and are confidential. A team member will contact you within 48 business hours with more information. Please review the full form before starting so you have any information or files you may need. The form must be completed and submitted in one sitting.
Client Demographic Information
Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Name of Individual Completing the Form
*
First Name
Last Name
Who are you filling the form out for?
*
My child
Myself
Another adult in my legal custody
A referral
Other
Contact Email Address
*
We highly utilize email to communicate during the treatment process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment progress.
Adult/Child's Legal Name
*
First Name
Last Name
Adult/Child's Preferred Name
*
First Name
Last Name
Adult/Child's Date of Birth
*
-
Month
-
Day
Year
Date
If filling out for a minor child, is the child adopted or in foster care?
*
Yes
No
N/A
Adult/Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
-
Area Code
Phone Number
Adult/Child's Birth Sex
*
Adult/Child's Gender
*
Adult/Child's Pronouns
*
Adult/Child's Race/Ethnicity
*
Adult/Child's Religion/Spirituality
*
Parent/Guardian Demographic Information
If the individual seeking therapy is a minor or has a legal guardian, please fill out this section. Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Legal Guardian #1 Legal Name
First Name
Last Name
Relationship to Client
Please Select
Mother
Father
Grandparent
Other Family Member
Legal Guardian
Legal Guardian #1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian #1 Phone Number
-
Area Code
Phone Number
Legal Guardian #1 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #1 Marital Status
Legal Guardian #1 Education Level
Please Select
Some High School
High School Diploma or GED
Some College
Associates Degree
Bachelor's Degree
Advanced Degree (anything beyond a Bachelor's)
Do you or your child/adult have another legal guardian responsible for making their medical decisions? If so, please provide that information below. If they do not have other legal guardians, you may indicate so in the drop-down and proceed on to the next section.
Please Select
Yes- There is another guardian
No- I am the only guardian
Legal Guardian #2 Legal Name
First Name
Last Name
Relationship to Client
Please Select
Mother
Father
Grandparent
Other Family Member
Legal Guardian
Legal Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian #2 Phone Number
-
Area Code
Phone Number
Legal Guardian #2 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #2 Marital Status
Legal Guardian #2 Education Level
Please Select
Some High School
High School Diploma or GED
Some College
Associates Degree
Bachelor's Degree
Advanced Degree (anything beyond a Bachelor's)
Insurance Information
Please provide all relevant insurance information for your child/adult below. Failure to submit the accurate, current cards may result in a delay in services and/or the client being responsible the cost of services.
Name of Insurance Provider
*
Please Select
Blue Cross Blue Shield
Kansas Medicaid- Aetna
Kansas Medicaid- Sunflower
Kansas Medicaid- UHC
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
*
First Name
Last Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
*
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Member Identification Number
*
Found on the front of the insurance card.
Member Group ID Number
*
Found on the front of the insurance card.
Please upload a copy of the front of your child/adult's current insurance card.
*
Browse Files
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Please upload a copy of the back of your child/adult's current insurance card.
*
Browse Files
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Do you or your child/adult have secondary coverage? (i.e. Medicaid and Private Insurance.) If so, please provide that information below. If you do not have secondary coverage, you may indicate so in the drop-down and proceed on to the next section. Please note, failure to report secondary insurance information may result in being responsible for the cost of services.
*
Please Select
No Secondary Insurance Coverage
My Secondary Insurance Isn't Listed
Blue Cross Blue Shield
Kansas Medicaid- Aetna
Kansas Medicaid- Sunflower
Kansas Medicaid- UHC
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
First Name
Last Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child/adult's current secondary insurance card.
Browse Files
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancel
of
Please upload a copy of the back of your child/adult's current secondary insurance card.
Browse Files
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancel
of
Psychological Services Information
Our office is open Monday–Friday, 8:30 am–4:30 pm, and talk therapy sessions are scheduled during these hours. We do not provide crisis or emergency services. If you or someone you care about is in immediate danger or experiencing a mental health crisis, please call 988 (Suicide & Crisis Lifeline) or 911 for local emergency services. Your safety and well-being matter. Please reach out for help right away if you are in distress.
Where are you requesting services?
*
In-Person at the Coffeyville Clinic Location
In-Person at the Baxter Springs Clinic Location
Remote Talk Therapy Services
Have you/has your child ever received a mental health diagnosis? If yes, please select it here.
*
Please Select
Autism Spectrum Disorder
Intellectual Disability
Anxiety
Depression
OCD
ADHD
PTSD
Other
Please upload any previous psychological assessments or diagnostic reports here.
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Please check any experiences you’ve/your child has had recently or at any point in the past. There are no right or wrong answers.
*
Frequent sadness
Excessive worry or anxiety
Crying spells
Irritability
Anger outbursts
Hyperactivity
Racing thoughts
Trouble focusing
Avoiding overwhelming things
Lower energy than usual
Trouble sleeping
Conflicts with siblings
Conflicts with family members
Difficulty making friends
Difficulty keeping friends
Other
Has the adult/child ever had feelings or thoughts about harming themselves?
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Yes
No
Has the adult/child ever attempted to harm themselves?
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Yes
No
Is the adult/child currently thinking about harming themselves?
*
Yes
No
On a scale of 0 to 10, (ten being strongest) how strong are thoughts of dying or attempting suicide currently:
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0
1
2
3
4
5
6
7
8
9
10
Has the adult/child ever been treated at an inpatient psychiatric facility?
*
Yes
No
If yes, please describe when, by whom, and the nature of treatment received.
Substance Use History
Some people reach out for counseling with questions or concerns related to alcohol or other substances. You’re welcome to share as much or as little as you’d like here.
Is substance use something you'd like support with right now?
*
Yes
No
Maybe
If yes or maybe, which best fits? (check any)
Alcohol
Cannabis/marijuana
Nicotine/vaping
Prescription medications
Other substances
Not sure
If yes or maybe, how would you describe the level of concern (if any)?
Mild curiosity or questions
Occasional concern
Ongoing concern
Urgent concern
Check if the child/adult has ever used or is currently using the following:
*
Past Use
Current Use
Never Used
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
How many caffeinated beverages does the child/adult consume in a day?
*
Has the child/adult ever smoked cigarettes?
*
Yes- They currently smoke.
Yes- They quit smoking.
No- They have never smoked.
If they have quit smoking, how long ago did they quit?
How many packs per day?
*
How many years did they smoke for?
*
Family History Information
Family relationships and support systems can shape what people are going through. Please share anything here that feels relevant.
Who currently lives in the home?
*
Partner/spouse
Children
Parent(s)
Other relatives
Roommate(s)
I live alone
Other
What languages are spoken in the home?
*
Is family or caregiver support something you're hoping to include in counseling?
*
Yes
No
Maybe
Not Sure
Are there family relationships that are important to know about right now?
*
Supportive
Strained
Changing
Not sure
Who currently lives at home with the child or adult? (Include sibling names and ages, please.)
*
Is there a history of any of the following in the child/adult's family?
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Autism Spectrum Disorder
Intellectual Disability
Learning Disorder
ADHD
Personality Disorder
Bipolar Disorder
Depression
Anxiety
Anger
Schizophrenia
Post-Traumatic Stress
Substance Abuse
Obsessive-Compulsive Disorder
Suicide
Unknown
Was the child/adult adopted?
*
Yes
No
Currently in foster care
Has the child/adult experienced neglect, abuse, or exploitation by a family member?
*
Yes
No
Medical History
Some health factors can affect mood, energy, or counseling logistics. Please share anything here that feels important.
Do you exercise regularly?
*
Yes
No
N/A
Are there any health considerations you’d like me to be aware of?
*
Chronic health condition
Neurodevelopmental difference (e.g., autism, ADHD)
Sleep-related condition
Chronic pain or fatigue
Recent illness, injury, or surgery
Pregnancy or postpartum changes
None/prefer not to say
Are you currently taking medications that affect mood/emotions, sleep, or focus?
*
Yes
No
Not sure/prefer not to say
Do you anticipate needing coordination with your prescriber?
Yes
No
Maybe
Do you need any accommodations for counseling sessions? (check any that apply)
Extra processing time
Movement breaks
Written follow-ups
Other
Have you had any significant illnesses, hospitalizations, or surgeries? If so, please explain.
Is there anything else health-related you’d like your counselor to be mindful of?
How much time do you spend being active each day?
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Name of Primary Care Physician
*
First Name
Last Name
Primary Care Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician Phone Number
*
-
Area Code
Phone Number
Date of Last Physical Exam/Wellness Check
*
-
Month
-
Day
Year
Date
Copy of Current Physical
Browse Files
Note: Failure to provide a clear, legible physical form dated within the last 365 days will result in a delay in being placed on the waitlist for services. Please call 620-330-9036 to have the form emailed to you prior to talking with your doctor.
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Does the child or adult have any allergies? If so, what are they?
*
Please list all of the child or adult's current medications, including name, dosage, time(s) of day given, purpose of the medication, and who prescribed the medication. Write N/A in the top row if they are not on medications.
*
Medication Name
Dosage
Time of Day Given
Purpose of Medication
Who prescribed the medication?
When was the med first prescribed?
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
If you ran out of room above, please continue to list the child or adult's medication information below.
Does the child or adult have any history of infectious diseases or other diagnoses we should know about?
*
Does the child or adult have a history of seizures? Please include the type and current treatment if so.
*
Educational History
Learning and school experiences can shape stress, identity, and daily functioning. Please share anything here that feels relevant.
What best describes the current situation?
*
Currently in school
Recently left school
Not currently in school
School-aged child(ren)/teen(s)
If in school, what setting best fits?
Public school
Private school
Homeschool
College or university
Trade/certification program
Other/not sure
Are there any learning or school-related concerns you're hoping to get support with? (Check any)
*
Academic stress or pressure
Attention, focus, or organization
Anxiety related to school
Social challenges at school
School avoidance or refusal
Transitions (new school, graduation, returning to school)
None/not sure
Other
Are any school supports currently in place?
*
IEP
504 plan
Informal school supports
Not sure
Not applicable
Does the child or adult attend school?
*
Yes
No
Name of School
*
What grade is the child or adult in?
*
Name of Teacher
*
First Name
Last Name
Did/Does the child or adult have an IEP/504 plan?
*
Yes
No
Anything else you would like us to know about the child or adult's educational or school history?
*
Please upload the child or adult's most recent/current IEP/504 plan.
Browse Files
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Therapy History
Many people receive different kinds of support at different times. Please share anything that feels helpful for us to know.
Has the client received any supports or services in the past or currently?
*
Yes
No
Not sure/prefer not to say
If yes, which types of support? (Check any that apply)
Counseling/therapy
Speech therapy
Occupational therapy (OT)
Physical therapy (PT)
Behavioral or skills-based support (e.g., ABA, social skills groups)
School-based services
Psychiatry/medication management
Intensive or short-term programs (e.g., IOP, PHP)
Other supports
Not sure
Are of these supports currently ongoing?
Yes
No
Not sure
Would you like coordination with other providers (now or in the future)?
Yes
No
Maybe
Is there anything else about past or current supports/services that you'd like me to know right now?
If yes, please provide the name of the provider and the service the child or adult received.
*
Has the child or adult received ABA therapy services in the past, including parent coaching services?
*
Yes
No
If yes, please provide the name of the provider and the service the child or adult received.
*
Does the child or adult receive speech, occupational therapy, physical therapy? Have they received them in the past? (If no, please skip the provider section below.)
*
Yes- Currently Receiving Services
Received Services in Past
No- Have Never Received These Services
Which therapy has the child or adult received?
Speech
Occupational Therapy
Physical Therapy
Name of Provider (Speech)
First Name
Last Name
Provider Address (Speech)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Speech)
-
Area Code
Phone Number
Name of Provider (Occupational Therapy)
First Name
Last Name
Provider Address (Occupational Therapy)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Occupational Therapy)
-
Area Code
Phone Number
Name of Provider (Physical Therapy)
First Name
Last Name
Provider Address (Physical Therapy)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Physical Therapy)
-
Area Code
Phone Number
Is there anything else you'd like our team to know about the child or adult's therapy history?
*
Current Behavioral Concerns
Some behaviors can make daily life, learning, or emotional safety harder. Sharing here helps us understand support needs. You can share as much or as little as you’d like.
Are there any current behaviors or safety concerns you’d like support with?
*
Yes
No
Not sure/prefer not to say
Please select if the child or adult currently engages in the behavior or has engaged in the behavior in the last six months:
*
Physical Aggression Toward Others (hitting, kicking, biting, punching, scratching, etc.)
Self-Injurious Behavior (hitting self, biting self, headbanging, cutting, etc.)
Property Destruction
Elopement
Sensory Concerns
Tantrums
Screaming/Yelling/Loud Vocalizations
Other
N/A
For children or those with autism-- If yes, which best fit right now?
Big emotional outbursts or meltdowns
Aggression toward others (hitting, kicking, biting)
Aggression toward self (head banging, self-hitting, etc.)
Property destruction
Elopement/running off
School refusal or avoidance
Difficulty following routines or directives
Unsafe behaviors relates to impulsivity
Other
None applicable
For teens and adults-- If yes, which best fit right now?
Self-harm behaviors (e.g., cutting, burning, etc.)
Urges to self-harm
Disordered eating patterns
Substance-related safety concerns
Risk-taking behaviors
Emotional shutdown or withdrawal
Anger outbursts or loss of control
Other
Not applicable
Is anyone currently in immediate danger? If yes, please contact emergency services or a crisis line immediately. •Crawford County 24/7 Crisis Save Line: 620-232-SAVE (7283) •Four County Mental Health Center – 24/7 Crisis Line: 1-800-499-1748. •Spring River Mental Health & Wellness – After Hours Crisis Line: 1-866-634-2301
*
Yes
No
If applicable, what's something you'd like me to know that is not listed on this form?
Are there any other behavioral concerns you'd like our team to know about?
*
How did you hear about our services?
*
Emergency Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Consent
The information I have provided for myself, my child, or the adult is accurate and true to the best of my ability and I am legally authorized to disclose this information.
Self/Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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