Kanza Mental Health & Guidance Center
Client Intake Interest Form
We're so glad you've reached out to Kanza Mental Health & Guidance Center. We are dedicated to inspiring hope and empowering wellness for individuals of all backgrounds. To help us connect you with the support you need, please take a moment to fill out the information below.
Fields marked with an asterisk (*) are required.
First Name:
*
Last Name:
*
Date of Birth (MM/DD/YYYY):
*
-
Month
-
Day
Year
Birth Gender:
*
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Parent/Guardian Name (if applicable):
Once we receive your information, a Kanza staff member willbe in contact within 48 hours of your submission. If you do not hear from us after 48 hours, please call (785) 742-7113. If you feel you are in crisis and in need of immediate support, please call our crisis line at (785) 742-3666. We're here to answer your questions and guide you through the next steps on your mental health journey. You're not alone — we're here to help.
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