Online New Client Information Form

1
What is the client's legal name?* This field is required.
First Name
Last Name
2
What is the client's preferred name (such as a nickname)?
3
What is the client's date of birth? * This field is required.
Date
Month
Day
Year
4
What is the clients age?
5
Is the client a minor?* This field is required.
YESNO
6
Who is the legal guardian/main contact?
First Name
Last Name
7
What is the best phone number to use to contact the client regarding scheduling and paperwork? * This field is required.
Please enter a valid phone number.
8
What is the client's mailing address? * This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
What is the client's email address?
10
What is the preferred method of contact?* This field is required.
Phone Call
Text Message
Email
No preference
11
What service(s) is the client wanting to obtain from our clinic?* This field is required.
Therapy
Medication Management
Community Support
Alcohol and Drug Evaluation
Co-Occurring Evaluation
Genesite Testing
Other
12
What is the client's preferred language for therapy?* This field is required.
English
Spanish
13
In order for us to choose the right provider(s), can you please give a brief description of the reason for seeking services? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
Our providers offer services in the office and via telehealth over Zoom. What is the client's location preference?* This field is required.
In Office
Telehealth
No Preference
15
Does the client have insurance?* This field is required.
YESNO
16
What type of insurance do you have?
Aetna
Ambetter
Blue Cross Blue Shield (from any state is fine)
EAP
Medica
Healthy Blue (Medicaid)
United Healthcare Community Plan (Medicaid)
Nebraska Total Care (Medicaid)
United Healthcare Commercial (NOT Medicaid)
Midland's Choice
Medicare
Midland's Choice
UMR
17
What is the policy holder's relation to the patient?
Self
Spouse
Dependent
18
What is the policy holder's date of birth?
Date
Month
Day
Year
19
Please upload a picture of the front of the client's insurance card. * This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Please upload a picture of the back of the client's insurance card.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
We partner with Legal Aid of Nebraska to have access to grant funding that covers a limited number of sessions at no-cost to the client. Would you like us to check on the client's eligibility for one of their grant programs?
YESNO
22
Has the client been negatively impacted by Covid in any way? This doesn't have to be just financially impacted. This can also be socially and/or mentally. * This field is required.
YESNO
23
Is the client a veteran?
YESNO
24
Is the client employed?
YESNO
25
What is the client's occupation?
26
Is the client currently involved in the AG industry?
YESNO
27
Is it okay of Legal Aid of Nebraska mails the client a one-time survey about the grand funding? It is okay to say no. This will not affect the client's eligibility.
YESNO
28
Are there any days or times that work better for scheduling appointments?* This field is required.Please select all that apply. Please note that we are not open on Fridays, Saturdays, or Sundays.
Mornings
Afternoons
Monday Morning
Monday Afternoon
Tuesday Morning
Tuesday Afternoon
Wednesday Morning
Wednesday Afternoon
Thursday Morning
Thursday Afternoon
Anytime
Varies
29
Has the client seen a therapist before? * This field is required.
YESNO
30
Who did the client see and when?
31
Has the client has inpatient mental health treatment in the last six months?* This field is required.
YESNO
32
Where was the treatment and when?
33
Does the client have history of any of the following?* This field is required.
Abuse (Mental, Physical, or Sexual)
Flashbacks and/or Nightmares
Addictions (Alcohol, Drugs, Prescriptions)
Experiencing or Witnessing a Life-Threatening Event
None
34
Does the client want to see a specific provider?* This field is required.
YESNO
35
Who does the client want to see? Please select all that apply.
Debra Erickson, Therapist
Jordan Hofmann, Therapist
Abby Gleason, Therapist
Alexis Bloomfield, Therapist
Anne Niffenegger
Cheryl Lockett, Nurse Practitioner
Christina Tipken
Cindy Betka, Therapist
Dave Hoyt, Therapist
Emma Todd, Therapist
Jessica Kroeger
Lauren Schenck, Therapist
Laurie Robinson, Community Support
Kimberly Parker, Therapist
Raquel Moreno-Izaguirre, Therapist
Sarah Bennett, Community Support
36
How did the client hear about our clinic?* This field is required.
Referred by an organization/professional
Referred by a friend/family member
Facebook Ad
Google Search
Drove/Walked Past
Other
37
Who referred the client to our clinic?* This field is required.
38
Is there any other pertinent information we should know?
Huge
Large
Normal
Small
Ok
Ok
39
How would you like us to reach out to you for scheduling?
Phone Call
Text Message
E-mail
40
Today's Date* This field is required.
Date
Month
Day
Year
Should be Empty: