Intake Forms

We want this process to be smooth and we are here to help you in any way possible.  If you have questions, please feel free to call the office with any questions you may have when completing your new patient paperwork. 

  • ​Please bring your photo ID, completed paperwork, and insurance card(s) with you to your appointment.  If you have questions regarding your insurance benefits, please call our office at me at 316-267-1601 and we will be glad to help. 

  • If you are completing your intake using TeleHealth, I will take a copy of your photo ID and insurance cards at the time of your TeleHealth appointment.  You can return your completed paperwork by uploading it to the secure client portal, mail, fax, or email to janels@thenextchapterICT.org

  • All co-pays, co-insurance, and deductibles are due at the time of service. 

  • We will confirm your appointment by text to the phone number and/or email address you provide.  If you are unable to attend your scheduled appointment, please kindly give us a 24-hour notice.

  • You should get an email from our client portal with all the intake documents to fill out.  We are adding links to this page to print the assessment tools if they are requested. 

DSM 5 Self Rated Level 1
Cross-Cutting Symptoms Measure  Adult

Print and complete this assessment if you are an adult ages 18 and older AND you are the client.

People with Masks
Self Report Symptoms

Print and complete this assessment if you are the client AND you are ages 15 years and older.  

Feeling Comfortable
DSM 5 Self Rated Level 1
Cross-Cutting Symptoms Measure  
Child ages 11-17

Print and complete this assessment if you are a youth, between the ages of 11 and 17 years old AND you are the client.

Mysterious Girl
DSM 5 Self Rated Level 1
Cross-Cutting Symptoms Measure  
Parent or Caregiver

Print and completed this assessment if you are the parent or caregiver for a youth client, between the ages of 6 and 17 years old.

Mother and Daughter Love

Rights granted: This measure can be reproduced without permission by researchers and by clinicians for use with their patients.

Rights holder: American Psychiatric Association To request permission for any other use beyond what is stipulated above, contact: http://www.appi.org/CustomerService/Pages/Permissions.aspx