Home  

New Client Information

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 within 24 hrs to talk about setting up the first appointment. If you have any trouble with this form call Renew at 913.768.6606 and press 0.

* Person Filling Out This Form:
Self
Parent
Physican's Office
Other
* Name of Person Filling Out This Form:
Client Name:
* The person who will receive therapy's age:
Services Seeking:
Individual Counseling
Family Counseling
Couples Therapy
Dietitan Services
Intensive Outpatient Program for Eating Disorders
Group Therapy
* Phone (cell):
* Can we leave a message?:
Yes
No
Home Phone:
Leave Message?:
Yes
No
Email address:
* Street Address:
* City, State, Zipcode:
* Best Method to Reach You?:
Cell Phone
Home Phone
Email
Payment Method?:
Insurance
Private Pay
If insurance, what provider do you have?:
If insurance, is it ok to see an out-of-network clinician to insure the best care for you?:
Yes
No
* Who referred you:
* Can we contact the person who referred you to thank them?:
Yes
No
Please describe the primary reasons you are seeking counseling support for yourself or someone else:
Is there anything else you think would be important for us to know?:
 
   
         
Renew 11695 S. Black Bob Rd., Suite B, Olathe, KS 66062
Office: 913.768.6606 Email: renew@renewkc.com

©2005 Renew
All rights reserved