Intake forms

Connecting with a new therapist can be stressful. At Responsive Mental Health Services LLC, we try to make the process easier for you by giving you several intake form options, including the option of downloading or reading the intake forms online, and bringing in your completed and signed forms. Below are links to downloadable forms for you to print, fill out, and bring to your first appointment. They can also be faxed to us at 816-817-1019. We do not recommend emailing them unless you have access to secure email protocols.  All of these will open in PDF format.

The Intake Forms

Demographics: (this is the form that tells us who you are and where you live)

Privacy Policy: (this tells you about your privacy and how we protect it, as well as explaining your rights and explaining when it might be necessary to disclose your private information. PLEASE READ THIS. By signing and returning the last page, you are telling us you have read and understood the information).

Informed Consent to Therapy: (this tells you about how to contact your therapist, explains risks and benefits of therapy, and how your insurance coverage affects your treatment. It also includes our social media and electronic communications policy. PLEASE READ THIS, and then sign and return the last page telling us you have read and understood the information).

Release of Information: (print one of these for each person you are willing to have information about your therapy. This might include family members and/or friends, and doctors such as your psychiatrist and family doctor, as well as case managers, school officials, and other people important in your life. On each, please specify what information they can receive, and any information they are specifically not allowed to have. Include name and phone number, and address or other contact information if you have it handy).

Also bring your photo ID (if adult), your insurance card(s), and any custody papers involving minors that specify who can make medical decisions for them. If you have any questions, please call us at 816-282-0144 x1 and leave a detailed message so we can call you back.

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