Here is the opening paperwork to receive services at Four County Mental Health Center. Please clearly print information on the forms and plan to come at least 20 minutes early to your appointment to complete the registration process. Thank you for choosing Four County Mental Health Center.

AIMS Admission Form 
Please make certain that all of the fields are properly checked or filled out.

Patient Information/Financial Agreement
All blanks should be completed. Whomever is responsible for any payment due needs to sign the bottom of the 2nd page.

Permission for Initial Treatment and Assessment
If the patient is a child, the parent or guardian should be the one to sign and date the form.

  RELEASE OF INFORMATION FORMS
Please ensure that all of the Xs and/or check marks are initialed or signed as indicated on the form. Also, please have someone sign as a witness on each release. Releases are not valid if they are not properly initialed and signed.

Release of Information Form - Blank
Release of Information Form - For PCP
Release of Information Form - For Schools

REGISTRATION FOR CHILDREN IN FOSTER CARE 
Send any history that is available for the therapist to read over.  Notify the foster parents of any appointment times.


We need the following releases for all foster children
Foster Agency
Foster Parents
Primary Care Physician
School District
Dept. of Children and Families (DCF)

Facilities and Hours of  Operation
(800) 499-1748
Independence Main - 3751 W. Main, PO Box 688, Independence, KS  67301(620) 331-1748
Coffeyville - 1601 W. 4th, Coffeyville, KS  67337
(620) 251-8180
Cowley - Strother Field 22214 "D" Street, Winfield, KS  67156 (620) 221-9664 or (620) 442-4540