Counseling Request

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Counseling Request

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We look forward to working with you!

We see counseling as a journey embarked on where the counselor and client approach change and healing together. We provide the highest quality of services to our clients through a team of professionally licensed counselors and pre-licensed counselors with varying levels of experience and specializations.

YOU MUST BE 18 YEARS OF AGE OR OLDER TO COMPLETE THIS FORM.

To request an appointment, please fill out the information below, and our counseling administration team will be in touch with you shortly to schedule an appointment.

WE DO NOT ACCEPT INSURANCE.

Work Entry

Please, tell us some information about yourself so that we can reach out to you.

First Name

First Name is required.

Last Name

Last Name is required.

Email address is not valid

Email is required.

Mobile Phone

Mobile Phone is required.

Birthdate

/ / Birthdate cannot be a future date.

Gender

Male Female

Address

Marital Status

Client First Name

Client First Name is required.

Client Last Name

Client Last Name is required.

To schedule counseling for minors, please list a parent or legal guardian's name and phone number below if different from contact information above.

Type of Counseling

Type of Counseling is required.

*For minors seeking counseling, we require a Minor Consent Form to be completed by both biological parents or a guardian with appropriate documentation.

Reason for Scheduling Counseling

Preferred Gender of Counselor

Male Female Either

Counselor's Qualification

Counselor's Qualification is required.
Campus Preference (Choose all that apply)

Lee's Summit Blue Springs Crossroads Telehealth Springfield MO - Hill City Church

Availability for Scheduling (Choose all that apply)

9:00 am - 12:00 pm 12:00 pm - 4:00 pm 4:00 pm - 8:00 pm Monday Tuesday Wednesday Thursday Friday Saturday

Are there any additional details or requests you would like to share with us?

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414 SW Persels Rd Lees Summit, MO 64081-2803