The Reframe Counseling LLC

The Reframe Counseling LLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

What are your pronouns?

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

Insurance details (Please put "N/A" if not using insurance)

If using insurance, please include the insurance company, plan name, and whether it is through an employer, health insurance marketplace, or Medicaid. Please upload a picture of your insurance card as well.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Day(s) available for appointments

Please select days that you are available for appointments. This is not a guarantee of therapist availability on selected days.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday My availability varies and I would prefer to request appointments as needed through client portal

Location preference

Where do you plan to attend appointments?

In-person (Wichita, KS) Telehealth (you must be present in the state of Kansas at the time of appointments)

Are there any other questions you have or anything specific you would like the therapist to know about?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Is there anything important for me to know about your preferences, needs, or expectations for therapy?

Limited to 600 characters

Reason for care

What brings you to therapy at this time?

Briefly share what is going on or what support you are hoping for right now

Limited to 600 characters

How long have these concerns been present?

A few weeks A few months Longer-term/ongoing Not sure

Have you worked with a therapist or a mental health professional before?

Yes No

If you have seen a therapist before, what was helpful or unhelpful about past therapy?

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.