Step 1 of 5 20% Name of Adult Requesting the Appointment* First Last Gender*MaleFemaleDate of Birth* Email* Enter Email Confirm Email We will never share your e-mail with anyone, period. Phone*ZipcodeHow did you hear about us?*Someone I trust recommended you.I found you online.I saw / heard your advertisement.Please Specify*If you Google searched, what did you search for? If you followed a link from another site, what was the site? If a phone book, which one? If a billboard, where at?If a flyer or brochure, on what topic?Which option BEST describes you?*I'm seeking help for myself.I'm seeking help for my relationship.I'm seeking help for my child. Spouse / Partners Name* First Last Length of Relationship (Years)*Other Parents Name First Last Children's Names and Ages*Example: Johnny Doe,13; Janey Doe, 7 For what are you seeking help?* Depression Anxiety Relationship Issues I have questions/concerns about the sexual part of my life. Anger Grief Spiritual Conflict Self-Harm Eating Disorder I'm not exactly sure. Other (Explain Below) My biggest relationship concerns are?* Communication Infidelity Sexual Difficulties Other (Explain Below) I'm seeking help for my child because he or she:* Seems sad. Is getting in trouble at school. Our family is going through a divorce. Is cutting or other self-harm. Might have an eating disorder. Is out of control. Is in foster care or is being adopted. Other (Explain Below) Any additional information you want to share to help us connect you with the right counselor for your situation? Which location do you prefer?*Online VideoSpringfield, MissouriColumbia, MissouriKansas City, MissouriThe best days for me to see a counselor are:* Monday Tuesday Wednesday Thursday Friday Saturday (limited availability) Scheduled 1st Appointment*YesNoTherapist*Josh Spurlock, MA, LPCShaun Lotter, MA, LPCSeptember Trent, MS, LPCRachelle Colegrove, MA, LPCMelissa Abello, MS, LPCLacey Wallace, CITKashina Harris, CITDate* Time of Appointment* : HH MM AM PM Financial ConsiderationsInsurance / Payment Plans / Scholarships*I DO NOT need a scholarship, payment plan, or TRC to file insurance claims. I would like TRC to submit claims to my insurance.*I may need an interest free payment plan. **I would like to complete an application for a Needs-Based Sliding Scale Scholarship.* You pay for your sessions and your insurance sends you reimbursement based on your policy. This is an outside contracted service and cost $5 per claim. ** No application is necessary to request a payment plan. Appointment Reservations* I understand that my appointment will be reserved with a credit or debit card. * As with hotels or rental cars we reserve appointment times with a credit or debit card. Cancellation Policy* I understand that if I cancel later than 5 pm the business day before my appointment I will be charged for the time I asked to be reserved for me. Information that helps us get better. This section is optional, but we would REALLY appreciate it if you completed it. What is MOST important to you when choosing a counselor?That you share my Christian faith and give Biblical counsel.That you are one of "the best" if not THE best.That your hours of operation are convenient for me.That you are covered by my insurance.That your prices are lowest.My experience with your website was...ExcellentCould be BetterUnsatisfactoryPLEASE tell us anything you can think of that could make us better. This iframe contains the logic required to handle AJAX powered Gravity Forms.