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New Patient Screen - Adulting Through Anxiety Group

Patient and Contact Information

Thank you for your interest in KCCAT's "Adulting Through Anxiety" program.

Please complete the following screener form, which should take approximately 15-20 minutes. This secure form helps us get a brief history of symptoms and treatment efforts to-date so that we can best guide you on whether or not this group is a good fit. 

If you have not already done so, please review our website for an overview on disorders we commonly treat, frequently asked questions about CBT/ERP, and our policies and fees (including important information regarding insurance). If you would prefer to complete this process by phone, please call and leave a message at (913) 649-8820, option 1, and a member of our intake coordinator staff will return your call to complete these questions over the phone. Please specify you are interested in the "Adulting Through Anxiety" program.

Please make sure you complete the entire form; if you do not reach the confirmation page, we have not ​received your information!

Information on the Prospective Patient
This question requires a valid date format of MM/DD/YYYY.
Patient's Gender *This question is required.
If applicable, for prospective patients age 18 or over only. This question requires a valid email address.
This referral is regarding… *This question is required.
Please note that if the prospective patient is 18 or older, they will need to complete a screen and/or reach out to confirm their interest in services. (If you have guardianship/power-of-attorney for an adult child or other adult family member, we will need documentation of that. Please note this in your screen and a member of our team will follow-up.)
Whom should we contact regarding this form? *This question is required.
What is your name and relationship to the patient? *This question is required.
Phone Contact Information *This question is required.Please complete this section with any applicable phone numbers for the patient and/or parent/responsible party. Enter your preferred/primary contact number first.