Request Talk Therapy Services
Please fill out the following form to the best of your abilities to help guide our intake and waitlist process. A member of our team will be in contact with you within 48 business hours of your request for services to provide you with more information. We encourage you to scroll through the entire document and note what information and files you will need to submit this request, as it will not save if you have to step away from it. Please complete in its entirety and submit all 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.
Child/Adult's Legal Name
*
First Name
Last Name
Child/Adult'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
Child/Adult's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Please enter a valid phone number.
Child/Adult's Birth Sex
*
Child/Adult's Gender
*
Child/Adult's Pronouns
*
Child/Adult's Race/Ethnicity
*
Child/Adult'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
Please enter a valid 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
Please enter a valid 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.
*
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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
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Choose a file
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
Drag and drop files here
Choose a file
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
Drag and drop files here
Choose a file
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Psychological Services Information
Our office hours are Monday-Friday from 8:30 am to 4:30 pm. All talk therapy sessions will need to be scheduled within this time frame. Born to Blossom does not provide mental health crisis intervention or emergency services. If you or someone you know is in immediate danger or experiencing a mental health crisis, please contact the Suicide & Crisis Lifeline at 988, or dial 911 to reach local law enforcement or emergency services. Your safety and well-being are our top priority, and we urge you to seek immediate help 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
What diagnoses does the child/adult currently have or suspect they may have?
*
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 all Current Symptoms the Child/Adult is Experiencing:
*
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/ forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Obsessive thoughts
Compulsive behaviors
Has the child/adult ever had feelings or thoughts about harming themselves?
*
Yes
No
Has the child/adult ever attempted to harm themselves?
*
Yes
No
Is the child/adult currently thinking about harming themselves?
*
Yes
No
On a scale of 0 to 10, (ten being strongest) how strong are thoughts of dying or committing suicide currently:
*
0
1
2
3
4
5
6
7
8
9
10
Has the child/adult 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
Please fill out the following section with as much information as possible.
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
Please fill out the following section with as much information as possible.
Who currently lives at home with the child or adult? (Include sibling names and ages, please.)
*
What languages are spoken in the home?
*
Is there a history of any of the following in the child/adult's family?
*
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
Is there anything else about the child or adult's family that you would like for us to know?
*
Medical History
Please provide as much information as possible about the child or adult's medical history and current health status. Ruling out medical causes for certain symptoms is highly important in the treatment process.
Do you exercise regularly?
*
Yes
No
N/A
How much time do you spend being active each day?
*
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
*
Please enter a valid phone number.
Date of Last Physical Exam/Wellness Check
*
-
Month
-
Day
Year
Date
Copy of Current Physical
*
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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?
*
Has the child or adult had any significant illnesses, hospitalizations, or surgeries? If so, please explain.
*
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
Providing information about the child or adult's educational history helps to provide background information needed for treatment planning. If the field does not pertain to the individual at this time, please write N/A.
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.
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Therapy History
Please provide us with as much detail as you can surrounding the mental health, ABA, speech, OT, PT, or other relevant therapeutic services that the child or adult has received. If they have received ABA therapy prior to this request, we will request a copy of their most recent treatment plan or a release of information to obtain that report from the provider.
Has the child or adult received mental health services in the past, including previous assessments?
*
Yes
No
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)
Please enter a valid 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)
Please enter a valid 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)
Please enter a valid phone number.
Is there anything else you'd like our team to know about the child or adult's therapy history?
*
Current Behavioral Concerns
Please provide us with information on barrier behaviors that the child or adult has engaged in in the previous six month period.
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, pulling teeth, etc.)
Property Destruction
Elopement
Sensory Concerns
Tantrums
Screaming/Yelling/Loud Vocalizations
Other
N/A
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
*
Please enter an emergency contact 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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