CLIENT CONTACT DETAILS
If you are scheduled for a family/couple's session, please identify ONE person as the "Identified Client".
IDENTIFIED CLIENT’S NAME
*
ADDRESS
ADDRESS
Street Address Line 2
City
STATE
ZIP CODE
CELLPHONE #
*
-
Area Code
Phone Number
WORK/ALTERNATIVE PHONE
-
Area Code
Phone Number
EMPLOYMENT STATUS
*
EMAIL
*
example@example.com - If minor, please specify whose email it is.
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
MARITAL STATUS
*
SEX ASSIGNED AT BIRTH
*
Male
Female
CURRENT GENDER IDENTITY
*
Male
Female
MTF
FTM
Genderqueer
Choose not to disclose
EMERGENCY CONTACT (NAME)
*
(RELATIONSHIP)
*
(PHONE #)
*
REFERRED TO OUR OFFICE BY
*
JEWISH FAMILY SERVICE – 333 S. 132ND STREET, OMAHA, NE 68154 – info@jfsomaha.com
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IF CLIENT IS A MINOR
Please complete this section
CUSTODIAL PARENT 1 NAME
PARENT 1 CELLPHONE #
CUSTODIAL PARENT 1 ADDRESS
IF DIFFERENT FROM CHILD
CUSTODIAL PARENT 1 SIGNATURE
I HEREBY GIVE CONSENT FOR TREATMENT TO BE PROVIDED TO THE ABOVE MENTIONED MINOR
CUSTODIAL PARENT 2 NAME
CUSTODIAL PARENT 2 CELLPHONE #
CUSTODIAL PARENT 2 ADDRESS
IF DIFFERENT FROM CHILD
CUSTODIAL PARENT 2 SIGNATURE
I HEREBY GIVE CONSENT FOR TREATMENT TO BE PROVIDED TO THE ABOVE MENTIONED MINOR
JEWISH FAMILY SERVICE – 333 S. 132ND STREET, OMAHA, NE 68154 – info@jfsomaha.com
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INSURANCE INFORMATION AND CONSENT
Please sign below if filing insurance
FILE MY MEDICAL INSURANCE
*
YES
NO
INSURANCE CARD SUPPLIED TO PROVIDER
*
YES
NO
Please upload a copy/photo of your insurance card (FRONT AND BACK)
Browse Files
Cancel
of
INSURED’S NAME (IF NOT SELF)
INSURED’S DATE OF BIRTH
/
Month
/
Day
Year
Date
I UNDERSTAND IT IS MY RESPONSIBILITY TO VERIFY COVERAGE WITH MY INSURANCE CARRIER
*
YES
NO
I HEREBY AUTHORIZE Jewish Family Service to furnish to the above insurance company(s) all information, which said insurance company(s) may request to secure payment of benefits. I hereby assign all money to which I am entitled for mental health expenses relative to services rendered by Jewish Family Service, but not to exceed my indebtedness to Jewish Family Service. I understand I am financially responsible to Jewish Family Service for charges whether or not paid by insurance. I authorize the use of this signature on all my insurance submissions.
INSURED OR GUARDIAN'S SIGNATURE
DATE
*
-
Month
-
Day
Year
Date
JEWISH FAMILY SERVICE
–
333 S. 132
ND
STREET, OMAHA, NE 68154
–
info@jfsomaha.com
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ADDITIONAL CLIENT INFORMATION
MY GOAL FOR COUNSELING IS:
*
IS THERE ANY FAMILY HISTORY OF TOBACCO USE/ABUSE, ALCOHOL USE/ABUSE, DRUG OR SUBSTANCE USE/ABUSE AND/OR MENTAL ILLNESS? IF YES, PLEASE EXPLAIN:
*
CURRENT MEDICAL CONDITIONS:
*
CURRENT MEDICATIONS:
*
PRESCRIBING PHYSICIAN:
ADDRESS:
PHONE NUMBER:
JEWISH FAMILY SERVICE
–
333 S. 132
ND
STREET, OMAHA, NE 68154
–
info@jfsomaha.com
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CLIENT DEMOGRAPHIC INFORMATION
For statistical and grant writing purposes only
WHICH OF THE FOLLOWING BEST REPRESENTS YOUR RACIAL OR ETHNIC HERITAGE?
*
White/Caucasian
Hispanic / Latino
Black / African American
Asian
Native American
Pacific Islander
Multi-Racial
Other
JEWISH
*
YES
NO
HOUSEHOLD ANNUAL INCOME
*
Under $15,000
$35,000-$49,999
$15-24,999
$50,000-$74,999
$25,000-$34,999
$75,000 and over
HOUSEHOLD COMPOSITION
List only people in the same house as the client
1) NAME:
DOB
JEWISH:
YES
NO
RELATIONSHIP:
IDENTIFIED GENDER:
RACIAL / ETHNIC HERITAGE:
White/Caucasian
Hispanic/Latino
Black/African American
Asian
Native American
Pacific Islander
Multi-Racial
Other
2) NAME:
DOB
JEWISH:
YES
NO
RELATIONSHIP:
IDENTIFIED GENDER:
RACIAL / ETHNIC HERITAGE:
White/Caucasian
Hispanic/Latino
Black/African American
Asian
Native American
Pacific Islander
Multi-Racial
Other
3) NAME:
DOB
JEWISH:
YES
NO
RELATIONSHIP:
IDENTIFIED GENDER:
RACIAL / ETHNIC HERITAGE:
White/Caucasian
Hispanic/Latino
Black/African American
Asian
Native American
Pacific Islander
Multi-Racial
Other
4) NAME:
DOB:
JEWISH:
YES
NO
RELATIONSHIP:
IDENTIFIED GENDER
RACIAL / ETHNIC HERITAGE
White/Caucasian
Hispanic/Latino
Black/African American
Asian
Native American
Pacific Islander
Multi-Racial
Other
JEWISH FAMILY SERVICE – 333 S. 132ND STREET, OMAHA, NE 68154 – info@jfsomaha.com
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TELE-MENTAL HEALTH CONSENT TO TREATMENT
Our guidelines for Virtual Counseling are the following:
By signing below I accept all terms and conditions mentioned above:
Printed Name of Client / Legal Guardian (if client is a minor)
First Name
Last Name
Date
/
Month
/
Day
Year
Today's Date
Submit
JEWISH FAMILY SERVICE
–
333 S. 132
ND
STREET, OMAHA, NE 68154
–
info@jfsomaha.com
Should be Empty: