Request for Psychological Evaluation

Foster Care Information

Contact InformationParent or Guardian for minors

What is your main concern or purpose for requesting an evaluation?

Please initial next to each statement to acknowledge them.

Failure to disclose primary insurance will result in a full cash charge. Do not report a secondary insurance without a primary insurance! MKC Counseling, LLC accepts Blue Cross Blue Shield of Kansas, Aetna, all Medicaid plans, and Medicare. If your plan is not listed, you are responsible for calling the number on the back of your insurance card to see if we are a provider. If not, you may pay out of pocket for services. You are responsible for calling your insurance plan using the number on the back of your card to check if pre-authorization is required for us to bill services through insurance. Not doing so may result in delayed scheduling.

Primary Insurance

Secondary Insurance