Online Appointment Requests and Telehealth Visits : What We Do : Dismas House of Kansas City, Inc.

Name:

Please list the name of the individual who will receive the service.

Consumer Name:

First Name *

Last Name *

Email Address: (Required)

Please provide us with a valid email address where we may contact you regarding your appointment.

Email Address:

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Contact Number

Please provide us with a valid phone number where you can be reached.

Phone Number:

Which kind of appointment would you like to schedule? (Required)

Please share any additional details you'd like:

Preferred Day and Time (Required)

Please let us know when you would like to come in for your appointment.

Referral Source:

If you are making this appointment on behalf of someone else, please list your name, contact information and relationship to the consumer below.

Consent

By submitting this form, you agree to allow Dismas House of Kansas City to contact you by phone and/email to schedule an appointment for services.

Please select one.

Online Appointment Request