This form is needed when you want to allow someone else to receive information about you. 

Common examples are:

  • If you are 18 years old or over and your parent wants to pay for therapy, you would need to complete this form to allow us to release your information to your parent.

  • If you have a 3rd party who is paying for therapy, you would need to give billing access to that 3rd party.

    • *If a 3rd party is paying for therapy, a 3rd Party Payer form is required.  Please call our office at 816-781-2349 and we will send the proper form to the 3rd party directly.

  • If there is a 3rd party, such as a caseworker, attorney, probation officer, school, relative or other individual, who you would like information released to, this form will be needed.

This form is also used to request a copy of your records or to request the therapist to write a letter or report for you. 

This is the complete PDF of our Privacy Practices if you would like to review that.

We would love to hear your thoughts, concerns or problems with anything so we can improve! Let us know comments, bug reports or questions.

Please fill out this form if you have a complaint regarding your service at our office.

Search for Therapy by Category

therapy online, online therapy, therapy online free, online counseling, counseling online, on line counseling, free online ocunseling, online counseling for free, online counseling for free, counseling free online, counseling online free, counseling online for free, online free counseling, tele therapy, online couples counseling, online christian counseling, therapy types, type of therapy, counselor types, types of counselor, family therapy, family therapy porn, family counseling, family counseling near me, family therapy near me, marriage and family therapy, family counseling service, family counseling services, therapy groups near me, therapist groups near me, counseling group, counseling groups, group counselor, group counseling, counselor group, psychologist groups, psychologist group,  counseling groups near me, therapy groups for anxiety, group counseling near me, group therapy for depression, group grief counseling, group grief counseling near me, family counseling center,

Counseling by Type

Multi Generation Family Piled Up In Gard

Counseling by Age Group

cognitive behavioral therapy, cbt therapy, therapy behavioral, cognitive therapy, cognitive behavioral therapy near me, cbt therapy near me, behavior therapy child, behavior therapy children, behavior therapy for child, behavior therapy for children, behavioral therapy child, behavioral therapy cildren, behavioral therapy for child, behavior therapy for children, behavioral therapy child, behavioral therapy children, behavioral therapy for child, behavioral therapy for children, behaviour therapy child, therapy for men, man therapy, men's therapy, counseling for men, men's counseling, men's psychologist, women's therapy, counseling for women,  behavior therapy near me, behavioral therapy near me, behaviour therapy near me, behavioral therapy for kids, cognitive behavioral therapy for insomnia,  behavior therapy adhd, congnitive behavior therapy anxiety, behavior counseling, cognitive therapy near me, behavioral therapy pediatric, cognitive behavioral therapy in depression

Counseling by Specialty

psychologist, counselor, therapist, therapist near me, counselors near me, psychologist near me, counselor mental health, counselor psychologist, counselor psychology, mental health therapist near me, psychological counselor, psychologist counselor, psychology counselor, counseling psychologist, counselor psychologist, psychologist counseling, psychologist counsellor, psychologist counselor, psychologist counseling, counseling psychologist, counsellor psychologist, psychologist for counselling, psychologist counselor, sounselor service, couknselor services, find a therapist, find therapist, finding a therapist finding therapist, therapist find, counselor services near me, free therapist, mental health therapsit, therapist for mental health, therapist mental health, general counselor, mental health counselor near me, talking therapist, talking to a therapist, therapist talking, therapist talks, counselor center, license professional counselor, psychological therapsit, talk therapy

Counseling by Therapist

Popular Therapy

stress psychologist liberty mo, stress psychologist kansas city, depression therapy liberty mo, depression therapy kansas city, grief counseling liberty mo, grief counseling kansas city, trauma therapy liberty, trauma therapy kansas city, therapy for anxiety liberty, therapy for anxiety kansas city, stress psychologist, health psychologist, therapy of depression, depression therapy, therapy depression, therapy for depression, grief counseling near me, grieving counseling near me, trauma in therapy, trauma therapy, traumatic therapy, therapy of anxiety, therapy anxiety, therapy anxiety near me, therapy for anxiety, therapy for anxiety near me, therapy near me anxiety, therapy near me for anxiety, anxiety about therapy, anxiety in therapy, anxiety therapy, anxiety therapy near me, therapy anger management, truama therapy, depression therapy near me, therapy near me depression, therapy depression near me, therapy for depression near me, therapy near me for depression, therapy for anger ma

Individual

Counseling

marriage counseling liberty mo, marriage counseling kansas city, marriage counseling kansas city mo, couples therapy liberty mo, couples therapy kansas city, couples therapy kansas city mo, marriage counseling, marrige counseling, marriage counseling near me, couples therapy, counseling for couples, counseling for couples near me, couple counseling near me, couples counseling near me, couple counselor near me, couples counselor near me, counseling for relationship, counseling for relationships, counseling on relationships, counseling relationship, counseling relationships, pre marital counseling, pre martial counseling, premarital counseling, relationship counseling, relationships counseling, counselor for relationships, counselor relationship, pre marital counselor, premarital counselor, relation counselor, relationship counselor, relationships counselor, premartial counseling, marriage and family therapy, marriage and family therapist,  therapy for marriage, counseling for divorce

Marriage Counseling

family therapy, family therapy porn, family counseling, family counseling near me, family counseling near me, family therapy near me, marriage and family therapy, family counseling service, family counseling services, family counseling services, structured family therapy, structural family therapy, family counseling center, family counseling centers, family counseling centre, family counseling center, marriage and family counseling, counseling for co parenting, co parent counseling, co parenting counseling, coparent counseling, counseling for parents, parent counseling, parental counseling, parenting counseling, parents counseling, counseling with parents, counseling parents, co parenting counseling near me, family counseling christian, christian family counseling, focus on the family counseling, marriage & family therapy, marriage family therapy, family counseling free, free family counseling, child and family counseling, children and family counseling, family counseling free,

Family

Counseling

emdr liberty mo, emdr kansas city, emdr kansas city mo, emdr therapy  liberty mo, emdr therapy  kansas city, emdr therapy kansas city mo, therapy emdr, emdr therapy, emdr, emdr therapist, emdr therapy near me, emdr therapist near me, emdr therapists near me, emdr treatments, brainspotting, brain spotting, tapping in therapy, therapy tapping, emdria, emdr treatment, eye movement therapy, eyes movement therapy, therapy with eye movement, dialectical behavioral therapist near me, emdr for ptsd, emdr ptsd, ptsd emdr, therapy for eyes, eye therapy, emdr near me, emdr certified, how does emdr work, emdr counseling, emdr ptsd therapy, emdr therapy ptsd, emdr therapy trauma, counseling emdr, emdr trauma therapist, emdr therapy for trauma, emdr trauma therapy, trauma therapy emdr, emdr therapist ptsd, ptsd emdr therapy, ptsd therapy emdr, therapy for ptsd emdr, therapy ptsd emdr, emdr counselling, emdr counselors, emdr therapy side effects, emdr anxiety, emdr for anxiety, emdr therapy for ptsd,

EMDR

Therapy

christian counseling liberty mo, christian counseling kansas city, christian counseling kansas city mo, christian counseling missouri, lds counseling liberty mo, lds counseling kansas city, lds counseling kansas city mo, lds counseling missouri, christian counseling, counseling for christians, christian counseling, christian counselor, counseling about relationship, lds counseling, lds marriage counseling, lds marriage counselors, lds counseling services, lds therapist, lds therapy, lds counseling near me, lds counselors near me, lds therapist near me, lds family services therapy, mormon therapist, christian counseling for marriage, christian counseling marriage, christian marraige counseling, christian counselor marriage,  christian therapy near me, christian marriage counselor near me, christian therapist near me, christian therapy, christian therapist, therapist christian, pastoral counseling,  christian psychologist, pastoral counselor, biblical counseling, spiritual counseling,

Christian Counseling

substance abuse counseling liberty mo, substance abuse counseling kanas city, addictions counseling kansas city mo, addictions counseling liberty mo, addictions counseling kansas city , addictions counseling kansas city mo, help with addictions liberty mo, help with addictions kansas city, help with addictions  kansas city mo, therapy groups near me, therapist groups near me, counseling group, counseling groups, group counselor, group counseling, counselor group, therapy groups, porn, addicting games, addictions, pornography, substance abuse, outpatient, pornography and depression, addictions to food, substance abuse counseling, counseling for substance abuse, counseling substance abuse, counselor substance abuse, substance abuse counselor, addictions to video games, outpatient rehab, addictions treatment center, addictions to social media, addictions of social media, counseling addicts, addict counselor, addictions of alcohol, addictions to alcohol, addictions counseling, addictions t

Addictions

Counseling

Norcon Family Counseling

To play, press and hold the enter key. To stop, release the enter key.

You've come this far, now take the next step!