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Overview of Counseling Programs
Court Ordered Substance Abuse Treatment Program
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Who We Are
Overview
Mission & History
Board of Directors
Contact Us
What We Do
Programs and Services
Overview of Counseling Programs
Court Ordered Substance Abuse Treatment Program
Private Counseling and Coaching Services
Calendar of Classes and Seminars
Program Fees
Recovery Housing
Transformational Housing
Online Appointment Requests and Telehealth Visits
News & Events
Newsroom
Event Calendar
Photo Gallery
Join Our Mailing List
Important Links
Portals
Donate
Pre-Registration Form for RSS Services
Intake Forms
New Consumer Registration Site
Pre-Registration Form
First Name (Required)
Last Name (Required)
Phone Number (Required)
Please provide us with a working phone number where you can be contacted.
Email Address
Provider/Site (Required)
Provider/Site (Required)
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Dismas House of Kansas City
Dismas House of KC/St. Kolbe Puckett
Academy of Addiction Services
Center for Women/St. Louis
COPS
Empowerment for Change
Footprints
Healing House
Not Affiliated with a Provider
Intake Appointment Type
Please note: The enrolling consumer must be present at a contracted Recovery Support Services Provider location for all telehealth intake appointments.
In-person Visit
Telehealth Visit
Desired Intake Appointment
Please include preferable dates/times for the intake appointment.
Are you a resident of the state of Missouri?
Participants must have state issued identification. Driver's License, State Issued ID, Department of Corrections ID are acceptable forms of identification.
Yes
No
If you do not have identification, please contact our offices before proceeding with this form.
Do you have a copy of your social security card?
A copy of your social security card will be required for the intake appointment.
Yes
No
If you do not have a copy of your social security card, please contact our offices before completing this form.
Upload ID Copy
You may upload the copy of your ID here. Identification will be required for the in-person visit.
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Upload SS Card
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Upload Completed Intake Packet.
Please upload a copy of the consumer's completed intake packet here.
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