Forms

Our Mission & Ministry

To help hurting people find genuine healing.

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New Client

Intake Packet 

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Current Client with

New Insurance

ANNUAL CONSENT

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Current Client

Annual Consent

NO CHANGES

Extra Forms 

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INTERN INFORMED CONSENT TO TREAT

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RELEASE OF CONFIDENTIAL INFORMATION

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ADDRESS &/OR NAME CHANGE

Card on File Agreement

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HIPAA Notice

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*