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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!

Please note that in order to allow our support staff time to enjoy the holiday season with their families, we will not regularly be returning voicemails or emails regarding new patient inquiries between Friday, December 22, 2017 and Monday, January 1, 2018.

New Patient Screens completed online using this form will be received as usual. Generally, you can expect to hear from a member of our staff within one week of completing this form. During this holiday period, however, it may take staff an extra couple of days to reach out.

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.
It looks like you're using a mobile device, such as a smartphone or tablet. Because this form has not yet been optimized for mobile devices, you may have difficulty answering some of the questions and we suggest continuing on your desktop computer.
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.
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.
Would your email address added to our Friends and Family Support Group contact list (you may opt in or out at any time, and we do not share our information with third parties)? 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.
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.