Ask About 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:
 


Once you have submitted the form, you should hear back from us by secure email within one to two business days, usually much sooner. To protect your privacy, you'll need to set a password to view the email. If by the third business day you have not heard back, something is wrong. First check your junkmail folder. SPAM filters have recently tightened and are screening out legitimate email both incoming to and outgoing from our office. If you cannot find any response from our office, please call 785-371-1414 and let them know that you are have submitted an Ask About Services Form.
 
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. As a matter of informed consent and treatment participation, we rarely accept requests for an adult client from anyone but the client. 
Date of Birth and Age of Client
Gender
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

Jessica Allison, LMSW

Lane Miller, LMSW

Rosa Knowlton, 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 (selecting this option gives you the best chance of getting on our schedule)

How Did You Hear About Family Psychological Services?
Google Search
Therapy Finder
Best of Lawrence
Facebook
Instagram
Radio KCUR, Kansas City 
Radio KLWN, Lawrence
TV Fox4, Kansas City
Read Dr. Wes' Books
Friend's Referral
Doctor's Referral: 
Other: 
Primary Insurance 

BCBS of Kansas
BCBS of Kansas City PPO
BCBS of Kansas City HMO*
KanCare (Aetna, Sunflower, and United MCOs)***
Aetna
United Health Care
Humana*
Cigna**
Other: 

*We do not accept this plan. You may have out of network benefits. 
**We are no longer accepting new Cigna cases due to poor reimbursement nor can we bill it out of network
***Rosa Knowlton is the only provider accepting new KanCare cases, and we awaiting her credentialling to make those referrals so your intake request may be on hold.

Because insurance plans vary greatly, we encourage you to take a photo of or scan both sides of your card and upload it below. 

 

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

Note: For children of divorced parents, 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.

Child/Adolescent
Adult*
Family
Relationship/Marital
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 www.fpskansas.com for details.

Provide a detailed summary of what brings you or your child to see us. Please don't leave this blank. We need this information to assign your case.

 

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