Please print all forms, complete prior to your first appointment and bring them with you. If you are not able to print them prior to your appointment, please inform and paper forms will be left in the waiting room area for you to complete. Please arrive 20 minutes prior to your first appointment if you need to fill out the paperwork in the office.

Intake Packet

The charge for my service is based on the customary and reasonable fee profile for professional services in my area. Charges for a clinical session include my time on your behalf, including record keeping and preparation.

Payment for services is required at time of service. If paying by check, please have the check made out in advance of our appointment. Other forms of payment accepted are cash and credit cards.

I do not accept any insurance but will provide a dual receipt for each session to enable you to file your mental health claim, if you so choose. The receipt will contain the required codes for your reimbursement, if that is an option for you. Please check with your insurance carrier for the information.

Diane K. Schmidt Counseling Services | 8575 W. 110th Street, Suite 304 Overland Park, KS 66210 | Phone: 913.730.6778 | Email: