Welcome to Horizons Mental Health Center! We are happy you chose us for your mental and behavioral health needs.
In this section you will find the New Patient Paperwork that may be filled out prior to your appointment to ensure a quick check-in process. If you have any questions about the paperwork, please feel free to call one of our care coordinators at 620.663.7595.
New Patient Paperwork
To better serve you, please review these forms before your visit:
and print and fill out forms prior to first appointment.
The following forms can be filled out online:
- Consent for Evaluation and Treatment
- Consent for Crisis Treatment (needed for children only)
- Release of Information
- Revoke Release of Information
- Consent for Telehealth Treatment
Cross Cutting Measures Form
You may also choose to fill out the Cross Cutting Measures form. This form must be filled out within 48 hours of the appointment. Be sure to select the appropriate form.
- APA DSM5 Level 1 Measure Adult
- APA DSM5 Level 1 Measure Child Age 11 to 17
- APA DSM5 Level 1 Measure Parent Or Guardian Of Child Age 6 to 17
Medication Evaluation Forms
- ADHD assessment
- Child Mania Survey
- SCARED (parent version)
- SCARED (child version) only if age 12 and up
What You Need to Bring:
- Insurance Card
- If no insurance-
- Proof of household income (Federal Income Tax Return, W-2, (3) Current Pay Stubs)
- Current benefit determination letter/application letter (Disability, Workers Compensation, Unemployment, General Assistance, Food Stamps)
- Medication List
- Guardianship paperwork (if applicable)
What Is My Financial Responsibility for Services?
You will be financially responsible for all insurance co-pays at the time of service, depending on the type of insurance plan you have. If you do not have insurance you may apply for placement in our Sliding Fee Scale program for self-pay consumers. We will also help you set up a payment plan for the services you receive.