Forms
Our Mission & Ministry
To help hurting people find genuine healing.
Please the select appropriate forms based on the state where counseling will be received.
Before completing Intake Paperwork please call our office at (402) 991-0611 ext. 2022
Someone from our leadership team will return your call within 24 hours to help find the provider who best meets your needs.
If you have already been assigned to a therapist, please complete the Client Intake Packet.
NE & IA
Client Intake Packet
Extra Forms: Please fill out an Intake Packet before any of the forms below.
INTERN INFORMED CONSENT TO TREAT
RELEASE OF CONFIDENTIAL INFORMATION
Card on File Agreement
Before completing Intake Paperwork please call our office at (785) 214-4012 then press 1.
Someone from our leadership team will return your call within 24 hours to help find the provider who best meets your needs.
If you have already been assigned to a therapist, please complete the Client Intake Packet.
KS
Client Intake Packet
Extra Forms: Please fill out an Intake Packet before any of the forms below.
INTERN INFORMED CONSENT TO TREAT
RELEASE OF CONFIDENTIAL INFORMATION
Card on File Agreement
Spence Counseling Center will file insurance claims on your behalf.
Benefits are not guaranteed until claims are processed.
Your therapist will go over your insurance benefits at your first appointment, so you are informed of your responsibilities. Spence Counseling Center accepts cash, checks, and most major credit cards including health savings accounts.
The Nebraska Gamblers Assistance Program (GAP) pays for confidential counseling with certified problem gambling providers to Nebraskans and their families who suffer a gambling addiction. A list of all GAP-Certified counselors in Nebraska is located at problemgambling.nebraska.gov GAP 24/7 Helpline – Call 1-800-522-4700
*This post is sponsored by and paid for by the Nebraska Gamblers Assistance Program*
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