Request of Services

This is NOT an intake form. We're only asking you to provide enough information for us to determine which FPS provider is most able to serve you based on expertise, insurance panels, and availability. We may also recommend another office if your case does not fit within our scope of practice. Please provide the following information and we'll have our office get back to you as soon as possible, typically within the same business day. DO NOT USE THIS FORM IF YOU ARE IN AN EMERGENCY SITUATION. CALL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM. If you need to stop and return to the form later, please click here:

Client's FIRST and LAST Name
 Promotional Code: 
Your Relationship to Client
Note: You must have legal authority for medical authorization to schedule an appointment for a minor. If the client is an adult you must have the client's expressed permission to schedule an appointment.
Date of Birth and Age of Client
Primary Care Physician
City and State of Residence
Daytime Phone Number
Other Phone Number
Best Email Address for Followup
Current School Attended (if applicable):
Preferred Therapist (if any).

Note: Due to staff schedules, we can't guarantee availability of a given staff person, but one of our therapy staff will reach out. 

Wes Crenshaw, PhD ABPP CST

Adrian Zelvy, LCPC

Jordan Mayfield, LSCSW. LCAC

Tamara Henley, LCPC

Sarah Doyle, LSCSW

Kelly Hughes, LSCSW

Susan Chase, LSCSW

Anna (Ah-Nuh) McCune, LMSW

No preference

Preferred Appointment:

Note: During the school year we attempt to limit evening appointments to elementary, middle and high school students

Daytime (9am to 2pm)

Afternoon (2pm to 5pm)

Evening (5pm to 8pm)

No preference

How Did You Hear About Family Psychological Services?
Google Search
Therapy Finder
Radio KCUR, Kansas City 
Radio KLWN, Lawrence
TV Fox4, Kansas City
Read Dr. Wes' Book
Friends Referral
Doctor's Referral: 
Primary Insurance 

BCBS of Kansas
BCBS of Kansas City PPO
BCBS of Kansas City HMO*
United Health Care**
KanCare (Aetna, Sunflower, United)***

Secondary Insurance
Client does not have secondary insurance
Client has the following secondary insurance: 
Responsible Party

Note: In cases of divorce, the party who presents the child must sign as responsible for any charges not covered by insurance, regardless of divorce or custody decrees.
Type of Service You're Seeking.
Please don't leave this blank. We need this information to assign your case.

Sex Therapy
ADHD Evaluation & Treatment (NOTE: We only evaluate clients who are seeking treatment for ADHD at FPS)
Other (describe below):

*We have a limited scope of practice for individual adults. See for details.

Provide a detailed summary of what brings you or your child to see us. 


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