Please enable JavaScript in your browser to complete this form.12Name *FirstLastEmail * Phone *Location *WichitaKissimmeeSt CloudMemphisIndianapolisLeominsterServices Needed *Individual TherapyFamily CounselingGroup TherapySA/MA/Child/So. EvalMedication ManagementPsychiatric EvaluationCouples TherapySession Type *In PersonIn Person - GroupTelehealthBoth - Hybrid Insurance Provider *Self PayBlue Cross/ Blue ShieldSunflowerUnited HealthcareAetnaHumanaCaresource*Please call 316-202-7051 if your insurance provider is not listed. Policy NumberWhy Are You Seeking Therapy? *I Am DepressedI Am Anxious/OverwhelmedStruggling with relationshipsI Am GrievingBattling AddictionI Want To Improve Self Confidence I Experienced Trauma Recommended (Family, Friends, Doctor)I Have A Mental Disorder OtherNextPreviousSubmit
