Please list the name of the individual who will receive the service.
Please provide us with a valid email address where we may contact you regarding your appointment.
Please provide us with a valid phone number where you can be reached.
Please let us know when you would like to come in for your appointment.
If you are making this appointment on behalf of someone else, please list your name, contact information and relationship to the consumer below.
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.