Let’s Connect!christy@sunflowerstatepsychology.com(316) 364-41538100 E 22nd St NBuilding 1500, Suite DWichita, Kansas 67226 Your Name * First Name Last Name Child's Name (if seeking services for your child) First Name Last Name Client's Date of Birth MM DD YYYY Email * Phone (###) ### #### Message * Terms of Use * By submitting this form via web portal, you acknowledge and accept the terms and risks of communicating your health information via this unencrypted electronic messaging. You understand that your information is saved by the web hosting platform (Squarespace). By clicking "Yes, I want to submit this form" you are continuing with this communication despite these terms and risks, and agree to hold Sunflower State Psychology harmless for unauthorized use, disclosure, or access to your information sent via these electronic means. If you are uncomfortable with these terms and risks, I am happy to communicate with you by phone or email. Yes, I want to submit this form. Thank you for contacting Sunflower State Psychology! I will respond to your message within 24-28 hours. I look forward to talking with you!