Secure Contact Form

First name

Last name

Email address

Phone number

What is your goal in coming in for services (what are the areas you want to improve in your life) & are you requesting any specific modalities?

What services are you seeking? (Select as many as you are wanting to engage in)

Therapy

Insurance eligible

Psychiatric Care

Insurance eligible

Intern Session (in training)

Reduced Self Pay/Pro Bono

Mental Health & Wellness Coaching

Self Pay

SomaVerse Ketamine Healing Program

email SomaVerse@mbhealingcollective.org directly to inquire about

What location are you requesting? Lawrence, Overland Park, Topeka or Telehealth (or hybrid)

How do you plan to pay? Self pay or Insurance (if so, what insurance carrier)?

DATE OF BIRTH

We will start an online portal for your secure information.

Would you prefer first available therapist? Are you requesting someone specific? (If they are not available, can we match you with another provider?)

What times are you available for services? (This helps us match you with someone who can meet when you are available, flexibility helps get in sooner).

May we send you our monthly newsletter, The Collective Pulse? Mental Health Tips, information, resources, community support, events.

Yes

Your information will be encrypted.