The Reframe Counseling LLC

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

Please provide day(s) and time(s) you would be available for session.

For example: Mondays before 3pm, Tuesdays between 2pm-5pm, Saturday mornings, etc. I

Limited to 600 characters

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

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.