Next Appointment Request [RC]

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Scheduling for the first time? Get started with our new client form.

Please Note: Our scheduling staff respond to inquiries during business hours only.
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Are you the client?* This field is required.
Yes
Please Select
Yes
No
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Name of Requester* This field is required.
First Name
Last Name
4
Relationship to Client* This field is required.
Provider, Caregiver, Teacher, Guidance Counselor, etc.
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Requesting Organization* This field is required.
Hospital, Facility, School, Independent Clinic, etc. –– if you are a Caregiver, Parent, etc., please write "N/A" here.
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Requester's Email* This field is required.
Please enter your email address where we can contact you regarding this appointment request, as needed.
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Full Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Zip Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Mobile Number* This field is required.
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Does the client agree to receive SMS messages at this phone number?By checking this box, you consent to receive text messages from Responsive Centers regarding your inquiries, orders, or services. You may opt-out at any time by replying STOP. For assistance, text HELP or review our Privacy Policy: https://responsivecenters.com/privacy-policy.php. Message and data rates may apply. Messaging frequency may vary. By checking this box, you acknowledge that you have read and understood our Privacy Policy and the terms and conditions written here. For better communication, scheduling, and completing paperwork, we recommend clients consent to receiving text messages from Responsive Centers.
Yes, client agrees.
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Clinician Name* This field is required.
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Client's Availability
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Preferred Time of Day
Morning – 8 to 11 a.m.
Lunch Hour – 11 a.m. to 1 p.m.
Afternoon – 1 to 5 p.m.
Evening – After 5 p.m.
Other
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Would you like to add any other information?
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Would you like to make an update to payment type or insurance details?* This field is required.
No, I don't have any updates.
Yes, I would like to update it now.
Yes, please contact me for updates before my visit.
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Payment Type* This field is required.
Please Select
Please Select
Insurance
Self-Pay
Choose Insurance or Self-Pay
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Insurance Provider* This field is required.
Please Select
Please Select
Aetna Kansas
Aetna Missouri
Ambetter Kansas
Anthem (BCBS Missouri)
Blue KC (BCBS Kansas City)
Cigna Kansas
Cigna Missouri
GEHA
Humana Kansas
KanCare
Medicare
MO HealthNet
QuikTrip
TRICARE (TriWest)
UMR Kansas
UnitedHealthcare Kansas
Other
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Other Provider* This field is required.
If selected 'Other', include the name of the Client's Insurance Provider
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Member ID/EAP Auth. #* This field is required.
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Policy Holder's Relationship to Client* This field is required.
Please Select
Please Select
Self
Spouse
Child
Parent
Sibling
Grandparent
Other
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Policy Holder's Gender* This field is required.
Please Select
Please Select
Male
Female
Other
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Insurance Card (Front)
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Insurance Card (Back)
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HIPAA Acknowledgement* This field is required.Clients have certain rights to privacy regarding their protected health information under the HIPAA Act. By checking the box above and submitting this form, the client is acknowledging that they may voluntarily be sharing sensitive information with our practice. While Responsive Centers cannot guarantee confidentially, we will never share any sensitive information with unknown third-party entities or use it for purposes outside of intake and scheduling. Please review our complete Privacy Policy here: https://responsivecenters.com/privacy-policy.php.
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Date
Today's Date
Month
Day
Year
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Signature
Clear
Should be Empty: