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 me at 316-759-9136 and I will be glad to help. 

  • If you are completing your intake through 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 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 you provide.  If you are unable to attend your scheduled appointment, please kindly give us a 24-hour notice.

Billing Release

DSM5 - Adult

DSM5 - Parent

Consent to Treat

DSM5 - Child 11-17

Adult Intake

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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