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New Patient Referral/Resource Request Form

Patient and Contact Information

Thank you for your interest in KCCAT. Please complete the following screener form, which should take aproximately 15-20 minutes to complete. This secure form helps us get a brief history of symptoms and treatment efforts to-date so that we can best guide you on what resources and options may be most appropriate.

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 prefer, you may 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 make sure you complete the entire form; if you do not reach the confirmation page, we have not ​received your information! An intake coordinator will reach out within 1-2 business days if we need additional information, have resource options we believe may be helpful to you, and to provide a point of contact before a team member reaches out to schedule.

To allow our team time to enjoy the end of year holidays with their families, our intake coordinator will not regularly be returning messages between December 18, 2021 and January 3, 2022.

New Patient Screens completed using this online form will be received as usual and processed beginning January 4, along with returning any outstanding messages. Although you should not expect a follow-up or scheduling call during this time, our estimated waitlist times have not changed. Your assigned clinician can let you know details specific to their availability, but generally we are scheduling new patient appointments for March–April 2022.

KCCAT is not able to provide immediate or walk-in appointments. Always alert any current medical or psychiatric provider, call 911, and/or report to the nearest emergency room for medical care during a psychiatric emergency.
Information on the Prospective Patient
This question requires a valid date format of MM/DD/YYYY.
calendar
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.
For most documents, KCCAT prefers electronic delivery by email, link, or a secure document signing service (when applicable). This reduces our use of paper and environmental costs associated with delivery, as well as provides faster service. For some documents, however, you have the option to receive by mail. Please select your preference below. *This question is required.At this time, billing documents for sessions are only delivered electronically.
I am contacting KCCAT because… (select all that apply)
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.
What is your name and relationship to the prospective patient? *This question is required.
This question requires a valid email address.
Would your email address added to our Friends and Family Support Group contact list? This is a free group open to adult friends and family members of those struggling with anxiety problems; for more information, please visit our Groups page.

You may opt in or out of the group mailing list at any time, and we do not share your email/information with third parties.
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.
KCCAT does not share your information with third parties. We will use your contact information, including email (if provided), to reach out as part of this initial screening, to discuss scheduling, and to coordinate treatment. You can always let us know your preferred method of contact.