New Patient Referral/Resource Request Form

Patient and Contact Information
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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!

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Information on the Prospective Patient
Patient's Gender *This question is required.
If applicable, for prospective patients age 18 or over only.
This referral is regarding… *This question is required.
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.