Prior to your scheduled appointment, you will receive a packet in the mail that includes all admission forms that need to be completed. If you prefer, a few forms are located below for your convenience. Please bring the completed forms with you to your admission appointment.
Client Admission Forms:
Client Information Face Sheet
Client Admission Information - Child/Adolescent
Client Admission Information - Adult
Use & Disclosure Form
In addition to the forms listed above, you will need to bring:
- Completed Child Behavior Checklist (CBCL). These forms were enclosed in your mailed packet. Unfortunately, we are unable to house this form on the website. For an additional copy, please contact FSGC at 785.232.5005
- Previous Treatment Information - Reports from previous providers are always helpful
- Copy of the insured's insurance card
- Income verifications - We offer a Sliding Fee Scale based on your household income and household dependents. If you wish to participate, please bring verification of the following that apply:
Wages (copy of recent check stub or most recent tax return)
Social Security Benefits
Public Assistance (Medicaid)
Retirement/pension (SSI / SSDI)
Child Support / Alimony
Unemployment Insurance
Other income not listed above
Note: If you have any questions regarding your financial obligation, please contact the Admission office staff.
We look forward to serving your needs. Feel free to contact our Admission office if you have questions. 785.232.5005
If you experience difficulties opening any forms, please contact our admission office. We will be happy to email or fax a copy of the forms.
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